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111 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only TO POSTINGS-� <br />eu.1K Wet\ <br />eiaq. p•Pr. <br />PulAc War\{ Fee <br />Tout Fee $ — <br />le„,PPl Fee Pta S <br />satinet Due 5 <br />ZD <br />—` Off,` <br />Malk`ng Address <br />City <br />Zip <br />Phone <br />>J� <br />-3775 <br />Annlmant <br />Mailing Address <br />City <br />Zip <br />Phone <br />Describe Proposed Work u' ^ l <br />W <br />Project Address (it known) 1 el t I it-',o Avg i= <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: a <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicato North v, <br />proposed structures on the lot • Show any proposed grading change= <br />• Existing and proposed utilities • Show measuiemel.is <br />DO NOT WRITE BELOW THIS LINE O <br />_ PERMIT CONDITIONS <br />1. All calls for Inspection shall be made 24 he& in advance - phone 259.8810. <br />2. All work shall be performed in accordance with this permit and current City of Ev.•,elt Design and Construction i <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL. : NUMBER 1-800.424-5555. Z <br />G"'W GJ (lNN'"r 'rn G 14� 4per��,A lN..t-�C+-±Zt/� C:-,e. <br />� rvttfvvs crrvs�( (Zoc�' , VJ <br />O <br />u <br />low J ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm. <br />less the City ofF.from any tad all claims for damages, costs, <br />expenses. or causes of of actin^ net may arise because of installation <br />C k e I O „ 4 _ 0.Cf and maintenance of the gr, � rent or v other rightupon <br />way use hereto <br />' , 1 I�-rC. -r CJ applied for and further agr� 1 remove Same upon notice from the <br />Approv5pt�9r Constructi DateCity and to replace public r damaged thereby. <br />N � INSPECTION ^- Date <br />Approved as Constructed $iydalure of Apirbant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />a <br />PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />Everett WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />Phone: 259.8810 PROJECT OVER 90 DAYS DURATION. <br />