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Datel <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />it (I <br />Owner <br />Address <br />City <br />public Wprka <br />Bldg. Dept. •-?Y <br />Public Worka Fee <br />Total Fee S <br />Lena Apple Fee Paid $ _- C �j <br />Balance Due S <br />Zip Phone <br />,t2lfff= 3 a9-)110_ <br />Applicarl Address City Zip Phone <br />1 k�GM.�ailing <br />WA1Describe Proposed Work — �G Int)S(-- <br />WA <br />Project Address tit known) 7�19 5- <br />Attach lour (4) copies of plans for proposed work - Draw to scale and nott the following as applicable: <br />• Property Limes • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />DO NOT WRITE BELOW THIS LINE <br />PERMIT CONDITIONS <br />O <br />1. All calls for inspection shall be made 24 hrs. in advance- phone 259.8810, <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standard.: and Sperifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1.800.424.5555. <br />S/ic &'low,C %U [`3� Q7N/_= %J�2' f�P<'/_'ObED F�t/s <br />/zi - 6'8 f/it/J Lc/iTi/ h�lS�'EC % To 7%,. <br />O <br />EGA 'n/i ✓G D<.'T, Ccrr�in6idi3 0A1 ZL,'14 ,0in/G DFl�i- S1 TEi �An/ <br />S 9O�G/Lf+�/T /S To /1 i,/,taC <br />e171 F • STt��r Tine' �'OVc/r�Fn/TJ <br />CI / <br />e <br />0 <br />a <br />Approved for C struch Date <br />i�� <br />FINAL INSPECTION Date <br />Approved as Constructed <br />i <br />PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone. 259-8810 - <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages, costs, <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace public property damaged thereby. <br />Signature of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST PE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION THIS PERMIT MAY BE <br />CANCELLED BY 1 HE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />