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Dat /� S Public Works Permit e <br />OIdD Dept. e <br />Application For <br />— <br />PUBLIC WORKS PERMIT Public Walk Feo <br />Tr•el Fee S — <br />— <br />Less Appi. Fee Paid S <br />20 160 <br />Salaece Due S <br />Print or Type Only <br />II <br />O ner alling Address Cityn Zip Phona <br />t, <br />- Appl cat Mailing Address LillyZip Phone <br />Work e �r� �04� C os l <br />Describe Proposed <br />Zia s r�r `4 tfL A �f <br />ii 0 AJ � 11 <br />.4A' 4 — <br />W <br />�B 7/- .E'ass z2VE - <br />Project Address (it known) <br />Attach lour (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />0 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 />M <br />DO NOT WRITE BELOW THIS LINE <br />O <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hr& in advance - phone 259-8615. <br />2. All work shall 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 you dig. TOLL FREE NUMBER 1 -800.424.5555. <br />z <br />C4aSS c' �AS.'r/dGT <br />f_— <br />/l <br />ALL QA.) <br />s ..- 7�,s <br />AGQ%v /T Gf/ilL dE Ts�E /I�.��icGNTr PFSP�tifiB��� <br />7-o A/akr NF4�S�J c f/ <br />Approved for Construction <br />/ilC//`� <br />FLNAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, VJA 98201 <br />Phone: 259-8815 <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-ol-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace public property damaged thereby. <br />i <br />�a <br />Signature of Applicant Da,e <br />WORK AUTHORIZED BY THIS PERMIT 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 />