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Date��� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />� �,, �,-a r L �. � (� � �M �� <br />Owner <br />Mailing Address <br />�������,� �:o,�s ���, �„� O. ) / ,` � - <br />p1�9 Dept � —�-1� L-�V' �lJ .. <br />Vu�Lc Nb�ks Fcn <br />Ta��� F�� s _ <br />LessAp01 FarPaN $ ._ <br />�nlance Duc 5 <br />7in Phone <br />City Zin Phona <br />asa- SaQ/ <br />DescribeProposedWork ��%�-K�4e�(/��_�kt�i�� - — <br />Prolect Adtlress (it knownl <br />Attach fow (4) copies ol plans lor proposed work � Draw to scale antl n0�e Ihe 1011ov+ing as apVlicable: <br />• Propeny Lines <br />• OutGne and dimensions ol all eaisting and <br />proposed structures on Ihe iot <br />• Exishng and proposed utildies <br />• Cen�erline ol street <br />• Indicale Norih <br />• Show any proposed grading changes <br />• Show measuremenis <br />PERMIT CONDITIONS <br />1. All calls for inspectio� shall be made 24 hrs. in advance- phone 259-8810. <br />2. All work shall be peAormed in accordance with ihis 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 />,r�� ����y�T /Lb7� �',E�C' <br />/� <br />Approved for Consiruclian <br />FINAL INSFECTION <br />Approved as Consiruc�ed <br />c�verett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Sireet <br />Everell, WA 98201 <br />Phone:259-8010 <br />Dale <br />Date <br />����� <br />7.� s-� 9 <br />ACKNOWLEDGEMENT JF CUNDITIONS <br />� <br />� <br />� <br />� <br />O <br />The undersigned ownr.dapplicant hereby agrees lo hold and save harm� <br />less Ihe City ol Everett Irom any and all cl�ims lor damac�es, costs. <br />expenses, or causes ol action that may arise because o� installalion <br />and mamtenarce ol Ihc unprovement or othe� ri�ht-ol�way use hereto <br />applieA lor and lu�thr.r agree5 �o remove 5ame upon notiCe from the <br />City and to ieplace public property dama9ed Ihereby. <br />Signaiurc ol Applicant Date <br />WORK AUT110RI2FD BY THIS PERti11T MUST 8E STARTED WITHIN <br />iB0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIG[NTLY PURSULD TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY TH[ CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OV[R 90 DAYS DUR�TION. <br />