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HnH <br />� � <br />H <br />9HN <br />r <br />H H <br />fC f] <br />H� <br />� M � <br />H� <br />z <br />o�d <br />��g <br />�� n <br />t"y� <br />HH <br />8� <br />H <br />C� � VJ <br />�Hv�i <br />HOtn <br />Date ��` `� _� <br />qpplication For <br />PUBLIC WORKS PERMIT <br />Prinl or Type Only <br />! � v„m�c Wm�s vmmn P� �T �Q. <br />e�ao o.�a • ���_Cx�.G3=7�C) <br />Pu�LclYorFSFca ---�--- <br />ro�a�.�� 5- <br />less nnc� �ne cmJ S <br />�aiance0ue 5 <br />Apphcant Mailin9 Add�ess Cdy LP Phone <br />Destnbe Proposed Work <br />Prolecl Address lil knownl <br />At�ach low �A) copies ol Plans tof prOposed work - Draw to scale antl note Ihe lollowing as apUhcahle. <br />• Properry Lines <br />• OuUine and dimensions ol all e��sting and <br />proposetl siructures on ihe lol <br />• EKisting and proposed utilities <br />• Centerhne of sirect <br />• Indicate North <br />{ Show any proposeA giading thanges <br />• Show measurements <br />PERMIT CONDITIONS <br />'�' 1. All calls lor inspec�ion shall be made 24 hrs. in advance - phone 259•88� 0. <br />2. All work shall be performed in accordance wilh ihis permit and current City ot Everetl Design and Construction <br />'' Standards and Specilications. <br />� 3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />' <br />I <br />,� <br />�_'Y <br />►�-dT {��� . <br />Approvetl loi Construclion Date <br />FINAL INSPECTION Date <br />Appwved as Constructed <br />eveiMt PUBLIC WORKS DEPAHTMENT <br />� 3200Cetlar5lreet <br />Everetl. WA 99201 <br />Phone:259�8810 <br />������ <br />3_�2-r�� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H• <br />wp <br />� / <br />� <br />O <br />H <br />N <br />O <br />a <br />The undersigned owner/applicanl hereby agrees IO hold and save harm� <br />less the City ol Everetl Irom any and all claims lor damages. costs. <br />expenses, or causes ol aclion that may arise because ol inslallation <br />and maintenance ol the iinprovement or other rlgh4of-way use hereto <br />applied for and �urther agrees lo remove same upon notice f�om ihe <br />City and to rep�ace pu6lic property damaged ihereby. <br />Signature ol AppGcaN �` �� <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DAT[ PERMIT IS ISSUED AND THERE�FTER IS TO <br />BE DIUGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />