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Date��d x <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />So„N.� <br />Mailing Address <br />ruoim vJo�ls Pr•�mn . <br />Bldp DeO�� � ����— <br />Pu��¢wmxsFoe � <br />TofalFee <br />La5lFpp� FeePp�d S <br />0alance Oue S <br />P—�; <br />_3S3 —P3aZ G <br />City 2ip Phone <br />Desaibe Proposed Work �� X oZ � Qil(Y.L .T (JYj_�� % P.I 1(`1,[N.lD <br />�,� <br />Project Address (if known) <br />Attach lour (4) copies ol plans for proposed work - Draw to scale and note �he lollowing as applicable: <br />• Pronerty Lines <br />•�utline er.d dimensions ol all ezisting and <br />proposed siructures on ihe lot <br />• Exis�ing a�d proposed utili�ies <br />• Centerline ol sireet <br />• Indicate North <br />• Sho�.v any proposed grading changes <br />• Show measurements <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 pertormed in accordance with ihis permit and current City ol Everett Design and Consiruction <br />Standards and Specifications. <br />3. Call Location Underground Service 4B hrs. belore you dig. TOLL FREE NUMBER 1-800•424-5555. <br />/1/c�T ,P�o <br />Approved for Construction <br />Date <br />FINAL INSPECTION Date <br />Approved as Consliucted <br />everetl PUBLIC WORKS DEPARTMENT <br />� 3200 CeEar Street <br />Everell, WA 98201 <br />Phone.259-8810 <br />ACKNOWLEOGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />0 <br />� <br />� <br />O <br />a <br />7he undersignetl owner/applicant hereby ag�ee& to hold and save harm� <br />less the City ot Eveiett Irom any and all claims for tlamages, costs, <br />expenses, or causes of action thal may arise because of inslalla�ion <br />and main7enance ol ihe improvemenl or o�he� nghhol-way use hereto <br />applied lor and further agrees to remove same upon notice Iwm the <br />City and to replace public Property tlamaged Ihereby. <br />Signature of Applicant <br />Dale <br />INORK AUTHORIZLD BY THIS PERMIT MUST BE STARTED WITHIN <br />1N0 DAVS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. ?HIS PERId1T MAY BE <br />CANC[LLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />