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Dales�i�, <br />Application For <br />F�UBLIC WORKS PERMIT <br />Print or Type Only <br />aiy z�� <br />PubhclYorASPermi�• _ <br />I �,�/'� <br />BIe9. JeP1. • 1_L_Li� — <br />i'obhc WoiW feo <br />TotelFee s <br />Le55F0�1 {eePaR1 S <br />Baian;rDuo a <br />s��!I VYl � <br />Applicant Mailing Address City Zip Phone <br />Describe ProposeJ Work 1�rf�� .��Y l� i'�--�'Y • <br />Prclec� Address (it known) <br />Attach four (4� copies of plans br proposed work • Draw to scale and note Ihe lollowing as applicable: <br />• Property Lines • Centerline ot sireet <br />• OuHine and dimensions of all exisCng and • loditate North <br />proposed structures on ihe lot • Show any proposed grading changes <br />• Ex�sting and proposed utililies • Show measurements <br />PERMIT CONDITIONS <br />1. All calls lor inspection shall be made 24 hrs in advance • phone 259•88� 5. <br />2. All work shall be performed in accordance with ihis permit and current City ot Everett Design and Consiruction <br />Standards and Specilications. <br />3. Call Location Undaryround Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />/t�0 j ,�'� c-c�,:�r= .l� <br />Approved lor Conslruction Dale <br />�� � <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />The undersigned owneUapplicanl hereby agrees to hold and save harm- <br />less Ihe Ciry ol Everett trom any and all claims lor damages, cosis, <br />expenses, or causes ot action ihat may arise because of installation <br />and maintenance ol �he im,.rovemen� or other righPot�way use hereto <br />applied lor and turther agrees to remove same upon notice irom the <br />City ard to replace public property damaged ihereby. <br />FINAL INSPECTION Dai= <br />Approved as Construded Signatur� ol Applicant Dale <br />cvcrctt PUBLIC WORKS CEPARTMENT VJORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />� 3200 Cetlar Streel 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />Everelt, WA 98201 BE DILI(;FNTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />Phone: 259-8815 CANCELLED BY THE GTY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OV[R 90 DAYS DUFATION. <br />