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oateG-/�-b�3 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />x ' '�BE�i :�s <br />oW�z� <br />.0 //JlQ� C.(J <br />Applicant <br />Address <br />�escribe Proposed Work ' ��FGU C.J7l/L�i�. <br />PUCIic Worka Peimit � � / � � <br />e�ep. oeol. • <br />Pu011c Worke ieo s _. � _ <br />To�el Fee <br />Lefs Appl. Fee PaiE S _� <br />Batan<e Oue S — � <br />Lo <br />�cne <br />[ ,C�i� ,�tk?f�a�SN °KZ�/U ; �3$ 22g2 <br />City Zip Plone <br />Project Address (if known) �� 6 /l,�'r/n � c( <br />At�ach (our (4) copies ol plans lor proposed wo�k - Draw to scale and note ihe lollowing as applicable: <br />• Property �ines <br />• Outline and dimensions of all ezisting and <br />proposed strucW res on ihe lot <br />• Ezisting and proposed utilities <br />• Centerline ol sireet <br />• Indicate Norih <br />• Show any proposed 9rading chanqes <br />• Show measuremenls <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259-881 5. <br />2. All work shall be performed in accordance with ihis permit and current City of Eoerett Design and Construction <br />Slandards and Specitications <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE MUMBER 1•$00•424•5555. <br />JY�proved lor Consiruc�ion / pate <br />���„'��' `'" "L-� �� �,,.� • �Y <br />FINAI INSPECTION Date <br />Approved as Construcled <br />everett PUBLIC WOFKS DEPAFTMENT <br />� 3200 Cedar Street <br />EverelL WA 90201 <br />Phone: 259�8815 <br />ACKNOWLEDGEMENT OF CONDITIOIJS <br />� <br />The undersigneC owner/applicani hereby agrees to hold and save harm- <br />less lhe Cily ot Everetl from any and all doims for damages, costs. <br />expenses, or causes ol ac�ion that may arise because of installation <br />and maintenancr of the Improvement or other rigM-of-way use hereto <br />applied lor and lurther agrees to remove same upon notice irom lhe <br />City and to replace public property damaged ihereby. <br />Signature ol Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE S7ARTED N�ITHIN <br />180 DAYS OF DATE PERA7IT IS ISSU[D AND THER[AFTER IS TO <br />BE C�ILIGENTLY PURSUEU TO COMPLETION. THIS PERMIT MAV BE <br />CANCELLED BY THE CITY UPON AYV `::lOPPAGE OF WORK ON THIS <br />PROJECT OVEF 90 DAYS DURAT.ON. � <br />i <br />