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Date � � " �� � <br />� <br />Applicalion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />� PUCLc Wnrks Pcrmi� • <br />� a� .,- � <br />Blaq. Dco�� <br />Pu�lic Works Fee 5 <br />Total Fce <br />�ess Appl Fco Paid $ <br />Balanco �ue � <br />Mailing Address <br />Describe Proposed Work <br />Project Address (if known) <br />Atlach four (4) copies ol plans lor proposed work - Draw <br />• Property Lines <br />• Oulline and dimensions ol all existino end <br />proposed struct�res on the lot <br />• Existing and proposed utilities <br />City <br />and note the following as applicable: <br />�� Centerline o( street <br />Y �ndiwle Norlh <br />• Show any proposed grading changes <br />• .ihow measurements <br />rnone <br />PERMIT CONDITIONS <br />1. All calls lor inspeclion shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All work shall be perlormed in acrordance with this permit and curreN City of Everetl Design and Construction <br />Standards and Specificatinns. <br />3. Call Location Underground Service 48 lirs. belore you dig. TOLL I�REE NUMBER 1•800-424•5555. <br />�:'�� ��`��C'��1��%� <br />;' ��7C��(l �l C�C/ <br />Approved for Construction Dale <br />FINAL INSPECTION Date <br />Approved as Consiructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everelt, WA 98201 <br />Phnne:259-8815 <br />(�'Z%�(l-/ <br />9 <br />c� <br />�::�Y-8� <br />ACKNOWLEUGEMENT OF CONDITIONS <br />� <br />� <br />H <br />� <br />O <br />a <br />The undersigned owner/ap�licant nereby agrees to hold and save harm- <br />less ihe City ot Everett from any and all claims for damages, costs, <br />ezpenses, or causes ol action that may arise because of installation <br />and maintenance ol the improvement or other right�o4way use nereto <br />applied tor and further a9rees to remove same upon notice Irom lhe <br />City and to replace public properry damageti thereby. <br />Signature o� �pplicant Dale <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WIiHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />8E DILIGENTI.Y PURSUED TO COMPLETION. THIS PERMIT MAV �E <br />CANCELLED BY THG CIT`( UPON ANY STOPP�GE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />