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Dater1%Y <br />Application For <br />PUBLIC WORKS PERMIT <br />PubLC woad Per II • �U /V7OO <br />q� <br />eleg. Oept. <br />Public; Works Fee <br />Total Fee S — <br />Less Appl. Fee Pale $ <br />Balance 0ue $ '11; <br />Print or Type Only j <br />�S AW1 j ^1142rd 4) %ad SG't� <br />�~ CO.130e / UU3 �<�7 - sc� - 0 3� <br />Owner <br />^/ Mailing Address City Zip Phone <br />1(ICFI'' 1 INC{Ii`e S�( -n(:5,Y���C�� Ewji,uodi c) wL7_ <br />Applicant Mailing Address City Zip Phone <br />Describe Proposed Work Gn r x 31 ' <br />r— <br />Project Address (if known) <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />LI <br />PERMIT CONDITIONS <br />1. All calls for in: pection shall be made 24 hrs. in advance • phone 259.881 5. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1.800.424-5555. <br />;! Tn �'� Cr�ivs•Tizvc �Fv <br />Approvetruction X Erate <br />Z S"� <br />FfFJAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259.8815 <br />14S /'F-le 1-'C4 X 1-S <br />7 --:2 �/ - 8 f- <br />ACKNOWLEDGEMENT OF CONDITIONS <br />Im <br />O <br />z <br />O <br />V / <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages, costs, <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace public property damaged thereby. <br />i iature of Applicant uue <br />RK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND 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 />0 <br />m <br />