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� <br /> ��� Puo�¢Wo�ks Pe�Nir �� " <br /> Uate ` <br /> p�Jp Dept� <br /> Application For <br /> PUBLIC WORKS PERMIT Pubio�������� S <br /> Lecs Aool Fee Pa�O $ <br /> BalanceDue S �� <br /> Print or Type Only <br /> „� �z,�,..,,�,� ����-�� ����� w �r������ 9�=0�%�, <br /> � ' 'Owner' r ,^� Mailing Address C ly � Zip Phone <br /> ��'S-.3�� <br /> Applicant Pdailing Address City Zip PM1one <br /> Describe Proposed Work �,/� � ��'�� ` � � <br /> W <br /> Prolec�Address lil known) <br /> 1 os�3 - 3� A� s�' � <br /> � <br /> Attach four(4)copies of plans for proposed work- Uraw�o scale and note ihe lollowing as applicable: � <br /> • Property Lines • Cenlerline ol street <br /> • Outline and dimensions ol all eaisting nnd • Indicate North <br /> proposed siructures on the lot • Show any proposed grading changes <br /> • Ezisting and proposed utilities • Show measurements M <br /> W <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS � <br /> 1.All calls lor inspection shall be made 24 hrs.in advance•phone 259•8810. <br /> 2.AII work shall be performed in accordance with this permit and current City of Everett Design and Construction <br /> Standards end Specilications. � <br /> 3.Call Location Underground Service 48 hrs.before you dig TOLL FREE NUMBER 1•800•424•5555. <br /> O <br /> � <br /> � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> r/� The undersipned owner/applicant hereby agrees lo hold and save harm� <br /> less Ihe City ol Everett Irom any and all claims for damages. costs, <br /> /I' ¢�0 expenses, or causes ol action lhat may arise becausc oi inslallation <br /> ` -���til �-� <br /> �_ �Q��� and maintenance of the improvement or other righl�of�way use hereto <br /> applied br and further agrees to remove same upon notice Irom ihe <br /> Appwved)arJConsiruction Date Cily and to replace public property damaged Ihereby. <br /> , ��;,�('"/____—��— <br /> / � �Y���i/� � ., .f -� ���`IC� <br /> ���� �,r.[ L �/ �� c� c�.�._- �/ , Date <br /> FINAL I SPE TION - SignaWre ol App icant <br /> Approved as Consiructed <br /> WORK AUTHORIZE� BY THIS PERMIT MUST BE STARTED W <br /> eveiett PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPIETION.THIS PERMIT MAY B' <br /> Everefl.WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON T� <br /> Phone:259�8810 PROJECT OVEF 90 DAYS DURATION. <br />