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Date��� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Ge�vl,qrn 7u c. <br />Owr.er <br />S p l�'�.1 <br />Applicant <br />Oescribe Proposed Work <br />Prolect ACdress (if known) <br />,� � <br />Address <br />Mailing <br />_ 3 .�d <br />City <br />Attach four (4) copies ol plans lor proposed work • Draw to scale antl nole the lollowing as applicable: <br />• Properry Lines <br />• Outline and dimensions of all eMisting and <br />proposed structures on the lot <br />• Existing and proposed utililies <br />,. <br />PvbLc Wo��� Peim�l � �o / 77 <br />BIEp. Deot • � <br />PeObcWor�sFee S <br />Total Fea <br />Lesa ADO� Fee Peid S <br />Bolance Due S 2� <br />• Cenlerline of street <br />• Inditate tianh <br />• Show any proposetl grading changes <br />• Show measuremenis <br />Phone <br />PERMITCONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shall be peAormed in accordance with ihis permit and current City ol Everett Design and Construction <br />Standards and Specifications. � <br />3. Call Location Underground Service 48 hrs. betore you tlig. TOLL FREE NUMBER 1-800•4Y4�-5555. <br />4,Ai�lY CHaiIGE Ii�l THE CF.IVEIJAY CUT MU3T EC <br />9Y THE FUbLIC 1JOFk:S DEFA��TMENT. <br />�.USE PUH�IC D�AINAGE P.`(ST�i" A� FROVIDET� <br />S.ANl' LOT GRADE CHAMGES MUST C�E APF'FOVED <br />FURLIL WORI::S INSf-GCTOR. <br />i.1:7nC;' CiTI' STRGETS CLEAN iyT. r"�LL Tii1G�. <br />C_��7r��lT�7�'� 7/�/�8 <br />y�/l/G <br />f,pproved lor Construction � Oate <br />FINAL INSPECTION Date -� <br />Approved as Constructed <br />Averett PUBUC WORKS DEPARTMENT <br />� 3200 Cedar Slreet <br />Everet4 WA 98201 <br />Phone: 259-Bfl10 <br />r�rr-rovE� <br />FOR DOWPIS�'OL'TS. <br />HY THE <br />ACKNOWLEDGEMENT OF CONDITIONS <br />Z <br />O <br />� <br />Y/ <br />O <br />a <br />The undersigned owneUapplicanl hereb7 ag�ees to hold and save h�rm- <br />less Ihe City ot Everett from any and all claims lor damages, costs. <br />ezpenses, or causes ot action !hat may arise because ot installation <br />and maintenance of lhe improvement or olher righbobway use hereto <br />applied tor and lurther agrees to remove same uDa� �otice Irom the <br />Cilv and to replace pu�lic property damaged thereby. <br />� <br />�O <br />5ignalure of Applicant � / � Date <br />WORK AUTHORIZED BY THIS PERMIT MIIST BE STARTED WITHIN <br />780 DAYS OF UATE PERMIT IS ISSUED ND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETIOPL THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATIOtJ. <br />