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Date�V� � Public Works Perm�l ._,__ <br /> Application For BItlB DrO��• <br /> PUBLIC WORKS PERMIT PUbTotelFeeFee s <br /> Less ApP�Fee PaiE S <br /> BalnnceDue S <br /> Print orType Only <br /> �A�..�c6�tz i�(�.r�e � �- ��o� a��- �3 <br /> Owner Mailing Address City Zip Phone <br /> ��Gb�' �IC�1'S �OC�zt�Y�'l�! l�.cl �1����7/h/ <br /> Applicant Mailing Address City Zip phone <br /> Describe Proposed Work V''.JI / <br /> W <br /> Project Address(if known) � <br /> Attach four(4)copies oi p�ans lor proposed work- Draw to sc�le and note the following as applicable: � <br /> • Property Lines • Centerline of street � �. <br /> • Outline and dimensions of all existing and � Indicate North <br /> proposed strucWres on Ihe lot • Show any pwposed gratling changes �� <br /> • Existing and proposed utilities • Show measuremeMs � ��I <br /> DO NOT WRITE BEIOW THIS LINE o <br /> PERMIT CONDITIONS <br /> � 1.All calls for Inspection shell ba made 24 hrs.in advance•phone 259•881 O. � <br /> 2.All work shall be peAormed in accordance with this permit and current City of Everett Design and Construction <br /> Standerds and Specifications. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1-800•424•5555. � <br /> � ���� ^��� � <br /> ��� <br /> � H <br /> � <br /> � <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applican�hereby agrees to hold and save harm� <br /> less the City of Everett irom any and all claims lor damages, costs. <br /> expenses, or causes of action that may arise because of installation <br /> and maudenance ol Uie improvement or other rigM�ohway use herelo <br /> applicd lor and further agrces to remove same upon notice Irom the <br /> Approved for Construction Date City and to replace public properry damaged ihereby. <br /> FINAL INSPECTION Date <br /> Approved as Construcled Signature ol Applicant Date <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST 8E STAR7ED WITHIN <br /> � 3200CedarStreet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone:259�8810 CANCELLED BV THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br /> il <br /> i' <br />