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Date_111JiL2r Public WorxsPeemit• <br />9idg Depr. • — <br />Application For c.t <br />PUBLIC WORKS PtRMIT PubbcWmks Foe --- <br />Teter Fee $ <br />¢O Less Appt Fee Paid $ — - <br />eGlancp Din $ �t--- <br />Print or Type Only-- <br />0 o <br />pri A) Sim C20 <br />Owner Mailing Address vCity Zip Phone <br />O Hit/7 <br />p a 0 U <br />Applicant Mailing Address City Zip Phone <br />Describe <br />Proposed W�ork^�2(/C <br />n"z u- Y � ! <br />^_� <br />nn -- W <br />Project Address of known) <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street /A <br />• Outline and dimensions of all existing and • Indicate North v♦ <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 O <br />PERMIT CONDITIONS <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 />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1.800.424.5555. <br />0 <br />0 <br />a <br />cica,_� \ r." I Cr,, tool <br />for Construction <br />In <br />as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />Ever Cedar Street <br />Everett, WA 98201 <br />Phone: 269-8810 <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 put c property damaged thereby. <br />Signature Applican Date <br />WORK AUTHORIZ BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DA1tE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />