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Dates�y(,-2�, <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Owner <br />Descri6e Propased Work � <br />Projec� Address (il known) ��� <br />��3 <br />Mailing <br />n�aumg <br />Y � �+� A,c <br />fres City <br />lress Ci�y <br />�� �z. i <br />—. /,� >.s �, ,r � <br />PUEi�¢ Worha Perm11 • ��L�� <br />BId�.DaO�� � .�� � <br />Pi�G�m Wcr45 Fee <br />Tolnlf'ee �� _ <br />LestAOP� Fae Paid S _ /� <br />aelance oue S �� i� <br />.�.� 4 9oao i 7 � � <br />Z�P Phone <br />Zip Phone <br />Attach lour (4) copies ol plans for p;�posed work - Draw to scale and note the lollox•ing as applicable: <br />• Property Lines • Centerline ot sireet <br />• Outline and dimensions ol all existing and • Indicate North <br />proposed siructures on ihe lol • Show any proposed grading changes <br />• Existing and proposed utilities • Show measureme nts <br />PERMIT CONDITIONS <br />1. All calls for inspPction shall be made 24 hrs. in ad��ance - phone 259•881 5. <br />2. All work shall be perlormed in accordance wilh this permit and current City of Everett Design and Consiruction <br />Stendards and Specilications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />4. ANY GRADING DONE ON THIS LOT <br />SURROUNDZNG LOiS WITN RAINWATER <br />5. DOWNSPOUTS FROM THE BUTLDING <br />DRAINAGE SYSTEM. <br />5. ANY CURB & GUTTER OR SZDEWALK <br />REPLACED BY THE APPLICANT, <br />SHALL BE DOi1E SO AS NOT TO IMPACT THE <br />RUNOFF, <br />ARE TO BE TIGHT-LINED TO THE PUBLIC <br />DAMAGED DORING CONSTRUCTION SHALL BE <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Cveretl, WA 96201 <br />Phone: :59-8815 <br />ACKNOWIEDGEMENT OF COK�ITIONS <br />W <br />� <br />� <br />� <br />O <br />� <br />Y/ <br />O <br />a <br />The undersigned ownedapplicant hereby agree:. b hold and save harm- <br />less Ihe Ciry of Everetl fwm any and all daims lor damages, costs, <br />expenses, or causes ol action that may arise because ol installation <br />and maintenance ol thc improvement or other righboFway usc herelo <br />applied for and lurther agrees to remove same upon notice irom the <br />Ci}ye�d to replace p� ropert damaged thereby. <br />Y <br />A / �J <br />lI `-U t�,� 3, � Z� S� <br />Sic�nature ol Applicant Date <br />WORK AUTIIORIZED BY THIS PERMIT MUST BE STARTED WI"fHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND IHEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANGELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />