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Date O�T"4Y <br />Application For <br />PUBLIC WORKS PERMIT <br />F'rint or Type Only <br />PoCI¢ Workt Fermit � Je�7i�� <br />Biaa oeo�. • <br />Pupbc Worke Fee s <br />ToblFee <br />leasAppl. iee PmE s <br />B�bnceDue i <br />Phone <br />�� C.i�Y Lip rnv�m <br />.__�.__.,. Mailing Hddress <br />Prolect Address (il known) _ � � � <br />A;7ech lour (4) copie5 0l plans for proposed work - Draw to scale and note Ihe lollowing as applicable� <br />• Property Lines <br />• OuUine and dimencions of all existing and <br />proposed structures on ihe lot <br />• Existing and proposetl utilities <br />• Centerline o� slreet <br />• Indicale Norih <br />o Show any proposed grading changes <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calls far inspection shall be made 24 hrs. in advance - phone 2$9-SBl 5. <br />2. All work shall be pertormed in accordarce with lhis permit and Current City of Everett Design and Consiruction <br />Standards ar,d Specilications. <br />3. Call Location Underground Service 46 nrs. before you dig. TOLL FREE NUMBER 1•800-$24•S55$. <br />�l' �c� f�i���r'�E� �`'�'%"�vs' JftT.�`� � �f��/ <br />��-C—/� � <br />as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar St�eet <br />EverelL WA 98201 <br />Phone�.259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />� <br />O <br />a <br />The undersigned owner/apPlicant hereby agrees to hold and save harm� <br />less Ihe City ol Everett Irom any and all claims lor damages, cosis, <br />ex0enses, or causes of adion Iha� may arise because ol installalion <br />and maintenance ol ihe improvemeN or other right�obway use hereto <br />applied for and lurther removr. same upon notice irom lhe <br />City and to re 1 pu6lic property a aged thereby. <br />i <br />� <br />Sig e ot Applicant �� � D f� <br />W O R K A U T H O R I Z E D B Y T NIS PERMIT MUST BE STAHTED WITHIN <br />1B0 DAYS OF DAT[ PERNdT IS ISSUED �ND THEREAFTER IS T O <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PFRAIIT M�V RE <br />CANCELLED �Y THE CITY UPON ANY STOPPAGE OP ANORi< `�N i ltib <br />PFOJECT OVER 50 DA1'S DJRATION. <br />C <br />�- <br />r. <br />n: <br />