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Date—.LSG� �� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Atldress <br />Address <br />Describe Proposed Work <br />Prolect Address lil known) <br />Vmrtc Worts Perm� <br />P�EB Oe01. � � � <br />PUPhcWo�ksFee s <br />tolal Fee <br />LP.55 RD�� Fee PaiC S <br />BTIROCC U�E `S <br />Z�p Phone <br />Attach four (4) copies ol Plans tor proposed wo�k • Draw lo scale and note the lollowin9 as applicable: <br />• Properry Lines • Cemerline of sVeet <br />• Outline and dimensions of all existing and • Indicate Norih <br />proposed structures on th� iot • Show any proposed grading changes <br />• ExiSting and proposed utitities • Show measurements <br />PERMIT CONDITIONS <br />1. All cells for inspection shall be made 24 hrs. in advance • phone 259•8810. <br />2. All work shall be pertormed in accordance wdh this permit and current City of Everett Design and Construction <br />Slandards and Specifications. <br />3. Call Locnlion Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800�424•5555. <br />l� �`"��� rE'C� <br />Approved for Construction Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 320U Cedar SUeel <br />Everett. WA 98201 <br />Phone:259-8870 <br />� -zs-90 <br />ACKNOWLEDGEMENT OF CONDIilONS <br />W <br />H <br />� <br />� <br />� <br />Q <br />� <br />� <br />� <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 for damages. cost:. <br />expenses, or causes of action that may arise because o! installation <br />and maintenance of the improvement or other ri�hl-ol-way use hereto <br />applied for and furttier agreas to remove same upon notice irom the <br />City and to rePlace public properry damaged Ihereby. <br />Date <br />Signaturr. of APPlicant <br />WORK AUTHORIZED b� THIS PERMIT MUST BE STARTED WITHIN <br />180 D4Y5 OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGC-NTLY PURSUED TO COMPLETION. THIS PEFMIT MAY BC- <br />('ANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />