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� _� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />� <br />Owner <br />Describe Proposed Work <br />Projett Addrr.r.s (if knewn) <br />d-�o - <br />Address <br />?u�LCWa�ksfe�mit � —�� A <br />BICp. Oept • a <br />PueIK worka Fae q ---_ <br />Tole1 Fae <br />Less RDO� Fee Peitl s �` O� <br />BalanceDue S � <br />�SP ��5� <br />�CJ.2 �� i a�� % � �/�/! <br />City Zip Phone <br />—/.3 /�%� �%v'`!s — <br />Ci�Y Zip Phone � <br />�� y . �s�� <br />Altach four (4) co�ies o� plans lo� proposed work • Draw to scale and note. Ceoterline of sheeii able: <br />� Propeity Lines • Indicate North <br />• Outline and dimensions of all existing and � Show any pioposed grading changes <br />pn�posed structures on the lot � Show measuremeNs <br />• Ezisting end propqsed utilities <br />PERMIT CONDITIONS <br />1. All cails for inspection shall be made 24 hrs. in advance • phone 259•881 5. <br />2. All v.�ork shal� be performed in accor�ance with this permit and current City ol Everelt De�ign and Construction <br />Sta�dards end Specifications <br />3. Cal; Location Underground Service 4B hrs. 6elore you dig. TOLI FREE NUMBER 1•80U-424-5555. <br />� S�TE C.�Jo,e,c Ts BE' �b,dF �`,e AP�,�', �v6v <br />I.Qyc.�i.rJcs [�9TEt' 8- /9-R� , <br />z�� 7_/f �f� <br />���[Gl' <br />fINAC INSP[C710N Date <br />Approved as Constructed <br />everett PUBLi: WORKS DEPARTMENT <br />� 32'JO Ce,iar Street <br />Everett. WA yn201 <br />Plione: G59�8B75 <br />ACKiVO\VLEDGEMENT OF CONfIiTIONS <br />W <br />H <br />� <br />� <br />� <br />O <br />� <br />� <br />� <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm• <br />less th� City of Everetl Irom any and all claims lor damages, costs, <br />expenses, or causes ol action ihat may arise because of installation <br />and maintenance ot ihe improvement or other right-ohway use her:to <br />apclied tor and furiher agrees lo remove same upon notice from ihe <br />Gity and to replace public roper dama9ed Ihereby. <br />Sgnature��fAppli nt �'��° <br />PORDAYS OF� DATE� PERMIT SEISSUEC AND NEREAFTER ISHTO <br />BE DILIGENTLV 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 />