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Dale�s� • <br />Application For <br />PUBLIC WORKS PERM�T <br />Print or Type Only <br />Owner <br />Adtlress <br />•I <br />Pubbc`Yo�Ms Permil � <br />oia9 oeo�.. �� /� � Z' <br />Publ¢ \Yorks Fao <br />Tolal Fec 5 <br />Less AOo� Fc� PaW S <br />o,•„�«o�� 5 <br />Ci�y Zip Phone <br />��cant Mailing Address City Zip Phone <br />Describe Proposed Work ���'r�2� <br />Project Address (if known) <br />Attach Inur (q� copies ol plans for proposed work � Draw �o scale and nole ihe tollowing as applicable: <br />• Properry lines • Cr.ntedine ol simet <br />• Outline and dimensions of ali existiny and • Indicale North <br />proposed siructures on the lot • Show any proposed grading changes <br />• Existing and proposed utililies • Show measurements <br />11:1 <br />PERMIT CONDITIONS <br />1. All calls lor inspec�ion shall be made 24 hrs. in advance � phone 259•881 5. <br />2. All work shall be performed in accordxnce with ihis permit and current City ol Everelt Desig� and Construction <br />Standards nnd Specilications. <br />3. Call l.ocalion Under,round Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />C ji � i /! . <br />Q��,���.��.�i� � �' �tTlt� ���tf� �G�CC:.�y � <br />% <br />� <br />��� �c %/ � <br />� �1� f���,������t.� <br />�� , / <br />-�{,� ��i2 E� ,1, i� � <br />� �ti <br />ACKNOWLEDGEMENT OF CONDITIONS <br />APP�o:ed lor ConstruCtion <br />FINAL INSPECTION <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />EveretL WA 98207 <br />Phone: 259-8815 <br />l/� �-�'S <br />W <br />M <br />Y <br />N <br />� <br />� <br />� <br />� <br />0 <br />Z <br />T,ie undersigned owner/applicant liernby agrees to holn and save hann- <br />less Ihe Ciry• of Everett from any and all claim: lor d�mages, costs, <br />expenses, or causes of aclion that may arise bec+us � oi installation <br />and ma;ntenance ol the improvement or olher ri�h��u4way we hereto <br />applied for and furiher a9rees to remove same uprn not�ce Irom Ihe <br />City and �o ieplace PUUIIc pwperty dainaged there6y. <br />Date Dat� <br />Siqnn�ure of ApPlican� <br />WORK AUTHORIZED BY THIS PERMIT MUST B[ STARTED WIif11N <br />180 DAl'S OF DATE PEHMIT IS ISSUED AND THEREAFTER I:> TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAV BE <br />CANCELLED BY THE CITY UPON PNV STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />