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Date.�d.$�� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print ur Type Only <br />� �'� YA �X.3 <br />Mailing Address <br />Sp,� � <br />Applicant Mailing Address City <br />Zip <br />Zip <br />�JC� — ? � r' <br />r�oi�� wo�ws ae�mn • . ���p " • " — <br />eme oeo�....--�c�'��-+-/-i�----... <br />Puviic Works Feo � <br />Tolal Feo <br />Less RpP� Fec Pa�d 5 <br />OalanceDuc S �'���— <br />Phone <br />De,scribe PropOsed Work NP��1N�/�� t�� CC �"�y �����—�-�!!---•r'�*af—� <br />Pro�ecl Address lil knov�N ��/2� �hd�� 'S� <br />Attadi lour (4) copies ol plans for pioposed work � Draw to scale and note ihe lollowmg as apPlicable: <br />• Proper�y Lines <br />• OWline and dimensions ol all existinp anA <br />proposed slructures on Ihe lot <br />� Exlsling and proposed ulilities <br />• Centerline ot street <br />• Indicalc Nmth <br />• Show any proposed gradinc� changes <br />• Show mcasure, �eNs <br />NE <br />PERMITCONDITIONS <br />1. All calls br inspection shall be made 24 hrs. in advance � phone 2S9•8810. <br />2. All work shall be perlormed In accordance with this permit and wrrent City o( Everett Design and Construction <br />Slandards and Specificalions. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />�;.ANY CHi1NGF IM TH� DRIVEI�IAY CUT <br />F.�l' THE FUE�LIC WORfCS DEF'ARTMENT <br />�.USF_ F'UL+LIC DRAINI-1��E 5Y8TF_ht /15 <br />L. A!�!\' �OT GkFlDE CHAN6[5 MUST E�E <br />: UE+LIC IJORk:S I�15FECTOf:. <br />i..I��GFi�, (-.).'i'Y �>TRFETS CL.EA�J (�1T � I_I. <br />PiUST L4- AF'1='RnVGD <br />F'FOVIDGD FOR DOWNSf'OUT'_;. <br />(1FF'ROVFD At' THE <br />' v /O%�'� �4 <br />Apnroved ipr Cons ruclion Date <br />� �_ , <br />/� ,��, �� <br />� -,> . ,,= , ,,,�� _ �/�., <br />FINAL INSPECTION 4� Date <br />Approved as Construcled <br />evemtt PUBLIC WORKS DEPARTMf:NT <br />� 3200 Cedar Stree1 <br />Evcret6 WA 98201 <br />Phona 259-8810 <br />TIPiEtI. <br />!t �NLEDGEMENTOFCONDITIONS <br />/ <br />W <br />� <br />�w <br />_ I <br />� <br />N <br />O <br />a <br />The undersignea .�. /apphcant hereUyagrees to hold and save harnr <br />less Iha Clty ol :- �,a11 Irom any and all claims for damac7es, costs. <br />expenses, or co �� ol action Ihat may arise because ol installatlon <br />and mainlenance ol ihe improvement or olher nght-of-way use hereto <br />applied lor and lurther agrees to remnve same upon notice Irom tlie <br />City and to repWce public properry damaged thereby. <br />�.�=� ,� ��- � ,s, <br />Sig ature of Applicant Dale <br />WORK AUTHOF�Z[D BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERM1IIT IS IS3UED AND THEREAFTER IS TO <br />BE DIUG[NTLY PURSUED TO COMPLETION. THIS PERMIT MAY B[ <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PFOJECT OVER 90 DAl'S DURATION. <br />