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Date —its * <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Public Works Permit • 2� ✓ �/ <br />Bldg. Dept. <br />Public Works Fee S <br />Total Fee <br />Less Appl. Fee Paid 5 <br />Balance Due $ --t ✓ ��� <br />My,GM:.ET Vlr'f l_Jd tj 4 7" ACny NEl2C7i 9iPe203 25 `-d L.L <br />Owner Mailing Address Zip ' Phone <br />m A_ G &e kr W t"r r l 47 ob M I_FnID /}Ur" 6yEe ET7' 9 w-2,SJ - <br />Applicant Mailing Address CA i Zip Phone <br />Describe Proposed Work SG W E12 . In it rJ e_'& L j <br />Protect 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 <br />• Centerline of street <br />• Outline and dimensions of all existing and <br />• Indicate North <br />proposed structures on the lot <br />• Show any proposed grading changes <br />• Existing and proposed utilities <br />• Show meaLuremenls <br />LIN <br />PERMIT CONDITIONS <br />1. All calls for inspection 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 />y Sll�ee %ylQiN Tom Co�/s%�vcTEv PE2 <br />Approved for Coni5truction ate <br />P.L INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />Ever Cedar Street <br />Everett, WA 98201 <br />Phone: 259.8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />Im <br />O <br />n <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 move same upon notice from the <br />City and to replace public properly maged thereby. <br />Signature o , pplicant ate <br />WORK AU .ORIZED 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 />