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Date_� J <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Publ�p WorkS Pe�mit + /.�f <br />Bieo. oeol. r �t) / <br />Puolic Worxn Fea <br />Total Fee s <br />Less AppL Fee PpiE S <br />BalenceDue S <br />%�-Lrii�� (,<l, l iFi�/� �=dE,��fl' ��.2-a�%�'% <br />Describe Proposed Work <br />Prolect Address (if known) <br />Attach four (4) copies of plans tor proposed work - Draw to scale <br />• Property Lines <br />• Outline and dimensions of all existing ano <br />proposeC struciures on !he lot <br />• Ezisting and proposed utilities <br />PERMIT CONDITIONS <br />note the lollowing as applicable: <br />• Centerline ot street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show rreasuremenis <br />1. All calls tor inspection shall 6e made 24 hrs. in advance • phone 259-881 $. <br />2. All work shall be pedormed in accordance with this permit and current City ol Everett Design and Construction <br />Standards end Specilications. <br />3. Call Location Underground Service 48 hrs. before you tlig. TOLL FREE NUMBER 1•800•424•5555. <br />��S//C�G -S�/'�-'E�� T�.E'/vc�� �lJ�/ — <br />� <br />i�✓O /���,,�G: c �-%�.,�-s ��=.F�,��i�—. <br />���1/i��� <br />Approved lor Conslruction Date <br />FINAL INSPECTION pate <br />Approved as Constructetl <br />everett PUBLIC WORKS DEPARTNENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone:259-8815 <br />i� <br />� zs=��?�- <br />ACKD:OWLEDGEMeNT qF CONDITIONS <br />W <br />H <br />� <br />� <br />H <br />� <br />0 <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm� <br />less the City of Everett irom any and all claims Wr damages. cosis, <br />expenses, or causes ol action that may arise because ol installation <br />and maintenance ol �he improvemenl or othr,r righFol-way use hereto <br />applied lor and luriher agrees to remove same upon notice from the <br />City and to replace public property damaged there6y. <br />Signalure ol Applicanl Date <br />WORK AUTHORI7_ED BY THIS f ERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFT[R IS TO <br />BE DILIGENTLY PURSUED TO COAIPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE GTV UPON ANY STOPPAGE OP WORK ON THIS <br />PROJECT OVER 90 DAVS DURATION. <br />H'y~T] <br />� 5 <br />� C�1 <br />O <br />� <br />� H <br />Z <br />K N <br />� � <br />[t] H <br />� <br />� <br />.� <br />� <br />� <br />H <br />� <br />ry <br />M <br />