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Date <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />C� <br />Applicant <br />Mei!ing Address <br />Mailing Address <br />City <br />Pu�llt WorMs Peprmil�• <br />BIOp.Oeo�-• U`' �O' <br />Pubiic Works Fac $ <br />Toial Fee <br />Less ApO� Fea Peitl S <br />Balence Oue $ <br />ne <br />�� <br />Describe Proposed Work �'r� p �h[L /� �� � �v �TLd(_—X--' � M(-�L�f�UL"Mc.�i)iC <br />Prolect Address (if known) <br />Attach lour (4) copies of plans lor proposed work - Draw lo scalc and note the lollowiny as applicable: <br />• Property Lines <br />• Outline and dimensions o� all existin9 and <br />proposed structures on the lot <br />• Existing and proposed ��tilities <br />Y Centerline ol slreet <br />• Indicate Norlh <br />• Show any propused grading changes <br />• Show measuremenis <br />P[RMIT CONDITIONS <br />t. All calls tor inspection shall be made 24 hrs. in advsnce - phone 259•881 5. <br />2. All work shall 6e performed in accordance with ihis permil anJ currenl City ol Everett Design and Cons�ruCtion <br />Standards and Specifications. <br />3. Call Location Undm�round Service 48 hrs. before you diy. TOLL FREE NUMBER 1•800-�i2�i•5Sb5. <br />� � �i c <br />�c i <br />r° � <br />/j�/" r <br />%� <br />�,L� �,c /� S- <br />� �. <br />`. P`�r�i� r�, <br />7 l <br />Approved for Construction Date <br />FINAL INSPECTION �ate <br />ApProved as Construcled <br />evere�t PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Slreet <br />Everetl, WA 98201 <br />Phone:259-BB15 <br />ACKNOWLEDGEMENT OF:.ONDITIONS <br />W <br />H <br />�1 <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersic�ned owner/applicant hereby agrees to hold and save harm- <br />less lhe Ci�y ol Everelt irom any and all claims lor damages, cosis, <br />expenses. or causes ol action thal may arise because ol installation <br />and maintenance of lhe imUrovement or olher rigM-of-way use hereto <br />applied lor and further agrees to remove same upon notice irom the <br />Ciry and lo replace public prooerty damaged thereby./L �,� ,� r!{ <br />� _ ,� � <br />d <br />�t a.��.�:�.�, .-.:1 �::� - <br />�ignature of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED ANO THEREAFTER IS TO <br />BE DILIGENTLY 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 />� � <br />�� <br />� <br />� �: <br />F <br />�� : <br />�� <br />H F^ <br />� Cr <br />O� <br />� F. <br />c` <br />C, <br />�1 <br />� <br />H .' <br />