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Date <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Owner <br />Madlnq <br />Describe Proposed Work <br />Project Address of known) <br />HIE <br />Public works Permit is <br />Bldg. Not. e <br />4ttaeh four 141 Copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines <br />• Outline and dimensions of all existing and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />Public Woke Fri <br />Tultl Fee S <br />�eae Abot Fee Paid =— <br />Bell.ce Due 9 <br />• Centerlme of street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />Phone <br />PERMIT CONDITIONS <br />I. All calls for inspection shall be made 24 hrs. in advance • phone 259.8810. <br />2. All work shalt be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before .,ou dig. TOLL FREE NUMBER 1.800-424.5555. <br />I'-*:E71.IRi•d 'ra 3Eidc-PER <br />NCI t=ORWAR1:THL. ORDIER ON PILE <br />_ tJNAEU. TO FORS1j=RD ..ate <br />FINAL INSPECTION Date <br />A.oprove❑ as Constructed <br />n <br />PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett. WA 38201 <br />Pnnno?59•eg10 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />LU <br />ca <br />0 <br />z <br />0 <br />H <br />0 <br />a <br />The undersigned Dwner/applicant hereby agrees to hold and save harm- <br />less the City of =verett from any and all claims for damages, costs, <br />expenses, or causes of action that may arise because of Installation <br />and maintenance of the improvement or other right-ol-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace public property damag- : thereby. <br />Signature pf Applicant D tC <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />ISO DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION, THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />