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6] <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Applicant <br />Address <br />Public Works Permit a JAL 0 <br />Bldg. Dept a <br />Public Works Fee § <br />Total Fee <br />Less Apnt Fee Paid g p <br />Balance Due <br />City Zip Phone <br />Q <br />Describe Proposed Work ld 20") C uleio z a . <br />(P a , ),f� I/e• F,,_, .,,. =F- Lr✓,4 -- <br />Project Address (if known) <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />LIN <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance • phone 259.8810. <br />'_ �' - 2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specilications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800.424.5555. <br />for <br />-a 7.9 <br />Approved as Constructed <br />PUBLIC WORKS DEPARTMENT <br />1&7T <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259.8810 <br />UJ <br />M <br />0 <br />n <br />R <br />U) <br />0 <br />a <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm. <br />less the City of Everett 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-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />Date City and to rye eublic property damaged thereby. <br />Date <br />Signature of Applicant — Date <br />WORK AUTHORIZED BY THIS P MUST BE STARTED WITHIN <br />180 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 />PROJECT OVER 90 DAYS DURATION. <br />ki i <br />