Laserfiche WebLink
Date�� � �"' <br />A�plication For <br />PUBLIC WC)l�KS PERMIT <br />� Type Only <br />�°0 �jQ� ��uy� <br />owner <br />Mailing Address <br />Pu01¢ Woika Farmil • �� ` � v <br />B�Op. Dep1. • _ <br />Pu��ic Worka fee <br />Tota� Fee s—/y /--y�-�y/� <br />Less Appt fea PaiG s{� <br />Balsnce Due <br />�L��i �820 ( <br />c��y z�n <br />K�r,����ore ��D� <br />1;ilY Zip <br />Project Atldress (il known) <br />Attach four (4) copies of plans lor proposed work • Draw to scale and note the following as applicable: <br />• Proper�y Lines <br />• Outline and dimensions of all existing and <br />proposed structures on the lol <br />• Existing and proposed u�ilities <br />PERMIT f;ONDITIONS <br />• Centerline ol street <br />• Indicate horth <br />• Show any proposed grading changes <br />• Show mea;ureme�ts <br />DO NOT WRITE BELOW THIS LINE <br />1. All ca4a lor ii:spection shall be made 24 hrs. in advance • phone 259•881 5. <br />2. All work shall be performed in accordance with this permii and current City of Everett Design and Consiruction <br />Standartls and Specifications. <br />3. Cali Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 7•800•424•5555. <br />L{ � l.�+r �� p-�-f'C//� ���5 <br />� <br />�.� //! �f/fNl�v /NTZ.) <br />�� <br />F i3-rL <br />�uj,c� S <br />FpG�nvrd as Constructed <br />� PUBUC WORKS DEPARTMcNT <br />� :7J0 Cedar Street <br />_�.�nr�C. VJA 98201 <br />� � .���. 25J�E815 <br />���� -� -z J - F3 6 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />O <br />� <br />� <br />O <br />a <br />The u�idsrsigned owner/applicant hereby agrees to hold and save harm- <br />less Ihe City ol Everett trom any and all claims lor damages, costs, <br />expenses, or causes ol action that may arise because ol installation <br />and maintenance ol lhe improvement or other right-of•way use hereto <br />applied lor and lurihur agrees to remove same upon notice trom the <br />City and to replace public property damaged thereby. <br />�11l � <br />Signature� ant � � Da�e <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />1B0 DAYS OF DATE PERMIT IS ISSUED AND THEFEAFTER IS TO <br />3F DILIGCi!TLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />�.4�!GeLLED BY THE CITY UPON ANY STOPPAGE O� WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />