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Date�o2�C�`S <br />Applica�ion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />r <br />Describe Proposed Work <br />ti .3�1 y �.. �� <br />Mailing Atldress <br />Mailing Atldress <br />.„ n <br />Zip <br />Uty up <br />ProleclAddresslifknown) �O!72�— L_�`rc. <br />Pu�i¢ WodsPmpm�it • / lg— Zz9 <br />BiaeDeot� [���Z�% <br />Pubiic Woiws Fce 5 <br />iolnl�ce - <br />Less A00�� Fcc Pm� 5 t�O <br />Balance Du¢ $ _ '�� <br />Attach lour (�) copies ol plans for proposed work • Draw lo scale antl note �he lollowing as applicable: <br />• Property Lines • Cenlerline ol slreet <br />• Outline and dimensions ol all existing and • Indicate Nath <br />proposed slructures on Ihe lot • Show any proposed gradinc� chanyes <br />• Existing and proposed ulilities s Show measuremenls <br />Phone <br />PFRMIT CONDITIONS <br />1. All calls lor inspection shall 6e made 24 hrs. in advance - phone 2$Q•88� 0. <br />2. All work shall be performed in accordance with ihis permil and currei�t City of Everett Design and Construction <br />Standards and Specilications. <br />3. Call Localion Underground Service 48 hrs. befoie you dig. TOLL FREE NUMBE:i 1-800•424-5555. <br />_ . _ i .. I . . ._ . . � r. �' . � ,� <br />..UJ'L I'�IYLl� llilriil'J�L Ji�.�I:=I'� YIJ 1. . . <br />..`�.i• .. , ���i'( , �_ ('I� . ., r I•I �,��r' nC f'IF'r: , <br />� 'V�/�' '/'!JU / -c� �!J c� �) B <br />Appro�d lor Construction Date <br />% <br />2 .,� � �/�� �" 7 'F'j� — <br />FWAL INSPECTIO /� Date <br />Approved as Consirucled <br />evrrcu PUBLIC WORKS DEPARTMENT <br />� 3200CedarStreet <br />Everett, WA 98201 <br />Phon¢ 259-8810 <br />W <br />H <br />� <br />� <br />� <br />� <br />♦ <br />�� <br />�w <br />V I <br />� <br />a <br />�CKNOVJLEJG[MENT OF CONDITIONS <br />The undersigned owner/applicant hereby a�rees to hold an� savo han <br />less Ihe City ol E��erell Irom any and all claims lor dairages. cos�. <br />expenses, or causes of action �hat may anse because of Installation <br />and maintenance of the improvement or other right-of�way use hereto <br />applied lor and furiher a�rees to remove same upon noDce Irom Ihc <br />City nd to replace public properry dama�ed thereGy. <br />Si nalh e of A plica� �Q � ���-D�te <br />9 P <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED INITHIN <br />1B0 DA'/S OF DATE PERAiIT iS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT M�Y BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORh� ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />