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Date�1� <br />Application For <br />PUBLI� WORKS PERMIT <br />Print or Type Only <br />Public \Varks Pormli • �3 a3 / <br />BId9. DePt � � � <br />Puelir, works Feo $ �7 � �3�— <br />Total Foo <br />Less AOP� Fee Paltl $ � <br />$ au�_ <br />eaia�oe om� <br />sys� <br />� ��I_PP �1���,�s _���r h'��k��l�e� �f'i/��-1 �r) 9't%�(L3 3.�`,s—' 4e�F/ <br />Address <br />Descrlbe Proposed Work <br />Prolect Address (if known) <br />;�-,� <br />Lip Phone <br />Attach four (4) copiec of plans for proposed work • Draw to scale and note the following as applicable: <br />• Property �ines <br />• Outline and dimensions of all existing and <br />proposed structures on the lot <br />• Existin9 and proposed utilities <br />PERMIT CONDITIONS <br />• Centerline ol slreel <br />• �ndicale North <br />• Show any proposed grading <br />• Show measurements <br />er� <br />� r; � <br />L'= <br />� :.: <br />---;- <br />r� <br />L+.: _ <br />GJ t O <br />; i_s , <br />1. All calls for inspection shall be made 24 Ivs. in advance • phone 259•881 5. <br />2. All work shall be performed in accordance with lhis permit and current City ot Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Undergrou�d Service 48 hrs. before you dig. TOLL FREE NUMBER 1-500•424•5555. <br />� / �ie �jOO�vl�r �V / �'�i�cj� J/�"/��7 / a2 �� <br />A�pr�ved lor Co�ructio y � Date <br />/ / <br />1.,-,� � /��-��.� s =2 -fY <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBIIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, wA 98201 <br />Phone: 259-887 5 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees to ho�d and save harm- <br />less the Ciry o( Everett from any and all claims for damages, wsts, <br />expenses, or causes of aclion that may arise because of installation <br />and maintenance of the improvement or other right•of-way use hereto <br />applied for and lurther agrees to remove same upon notice from the <br />Citv and to replace public property damaged thereby. <br />_ _ '6.�.S�qa�.�� <br />-^--- <br />i s;ure ot Appli t Date <br />ORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE UILIGENTLY PURSUED TO COMPLETION. THIS PERM�T MAl' BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />