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Date S � �ia <br />qpplication For <br />PUBLIC WORKS F'EFiMIT <br />Print or Type Only <br />6 1 S F L- <br />ng Address <br />yfl ,/� <br />Address <br />Describe Proposed Work <br />� <br />Prolect Address (if known) /Y�o � '�.� r. <br />Puehc woas Po�mn n _— <br />eiae oeoi . Co�/ � ��Gi � <br />Publro Works Fee <br />Total Fee `S <br />lCsS ApPI. F¢O Vaitl 5 <br />Baiance Due S <br />t c c..-� y�� r <br />Gity Zip <br />;�,��P��_-� � s z r � <br />CitY Zip <br />_ # �r <br />Attach lour (4) copies of plans fur proposed wod� - Draw to scale and no�e lhe lollowing as applicable: <br />• Propeiry Lines • Centerline of sireet <br />• Ou�line and dimensions ut all eristing and • Indicate North <br />proposed siruclures on ihe lot • Show any proposed grading changes <br />• Existing and proposed ulilities • Show measurements <br />y �/— 7'f f Z <br />rnone <br />3,� S'— �' 2 z s' <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance- phone 259•8810. <br />2. All worM shall be performed in accordance with this permit and current City ol Everett Uesign and Consiruction <br />Standards and Speci(ications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800-424•555.�i. <br />"-?BI�IC._ �`(O�K.S NOT �QV 1 f�-`YJ <br />Appioved for Construction Date <br />FINAL IN3PECTION Date <br />Approved as Conslructed <br />everett PUBLIC WORKS DEPARTMEN7 <br />� 3200CedarStreet <br />Everett, WA 98201 <br />Phone:259�8810 <br />Z <br />O <br />� <br />N <br />0 <br />a <br />ACY.NOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less ihe Ci�y of Everett Irom any and all claims for damages. costs, <br />ezpenses, or causes of action that may arise because ol installa�ion <br />and mainlenancc of lhe improvement or other right-ol�way use hereto <br />applied lor and further agrees to removs same upon notice Irom ihe <br />City and to replace public properly damaged ihereby. <br />Si9nalure of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STAATCD WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUEG 70 COMPLETION. THIS PERMIT MAY B[ <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK Oh THIS <br />PROJECT OVER 90 DAYS DURATION. <br />