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Date�.��� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Owner <br />Applicant <br />Mailing <br />City <br />81.�g / <br />Publlc Works Permi� � _ <br />ema o�o� . <br />PuEIICWarkeFoo g <br />Totnl Feo <br />Leae AppL Fee Peltl $ <br />Belenco Dua S � �— <br />�����`T�.�iJ�� <br />2ip Phone <br />. - � �� � _i � : �: C �•. - � � <br />Project Address (if known) <br />� <br />Aitach lour (4) copies of plans lor proposed work - Draw to scale and note the following as applicable: <br />• Property Lines ,• Centerline of street <br />• Outline and dimensions of all existing 2iid • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • uhow measurements <br />PERMIT CONDITIONS <br />1. All calls tor inspection shall be made 24 hrs. in advance - phone 2$9•8815. <br />2. Ail work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standerds and Specilicationa <br />3. Call Localion Underground Service 48 hrs. betore you dig. TOIL FREE NUMBER 1•800-424-5555. <br />���.�f�-� � �� <br />App;ovedforConstruction /� D te <br />�/,i� ��� <br />�%S<�e'� �— ,6 �o <br />FINAL INSPECTION Dale <br />, Approved as Conslructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 CedarStreet <br />�I Everett, WA 98201 <br />Phone: 259�8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />O <br />� <br />� <br />� <br />a <br />The undersigned owner/applicant here6y agrees to hold and save harm- <br />less the City of Everett trom any and all claims for damages, costs, <br />expenses, or causes of action that may arise because of installation <br />and mainlenance of the improvement or other right-oi-way use hereto <br />applied lor and further agrees to remove same upon notice from the <br />City and to re� public properry damaged thereby. <br />l/ <br />�� � � ��^- <br />l..i.F: ,, i , C v' i_�,�'/� r' <br />Signature ol Applicant �' ( Date <br />WORK AUTHORIZED BY TI115 PERMIT MUST BE STARTED \NITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED C3Y THE CITY UPON ANV STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />