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Date_:=L� �_J <br />AppliCation for <br />PUBLIC WORKS PERMIT <br />Print or Type Jnly <br />n�amng <br />Desc�ibe Proposed Work <br />P�oie[t Address (il known) <br />r„ni�c wo�xs narmn .�--- <br />oinp oen� � R� � ��I � <br />PuCLCWorxefee 5 <br />ialnl fee <br />Llsf Appl Fea P0�0 S <br />BpldllCfl �YO S <br />��U I �.c������� <br />Zip Hhone <br />Zip Phonc <br />At�ach tour i4) copies ol plans lor proposed work - Draw to scale and note the lollowing as applicable: <br />• Property Lines • Centerline ot street <br />• Ou�hne and dimensions ol all eais�ing and • Indicale North <br />proposeA structures on the �ot • Show any proposed yrading ctiangr.s <br />• Eaisting and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />All calis for inspeclion shall be made 24 hrs. in advance � phone 2S9•881 5. <br />All work shall be perlormed in accordance with Ihis permit and a�nent Ciry of Fverett Design and Construction <br />S�andards and Specificetions. <br />Call Location Underground Serv�ce48 hrs. belore you dig. TOLL FREE NUMBER 1-800•424-555b. <br />�f�G.+U-i !.C/OZYs. %-F�:,�>z/!� �r%f-`"��'y:',�.N <br />tor ConSlruclion <br />Date <br />FINAL INSPECTION Dale <br />Approved as Constructed <br />everelt PUBUC WORKS DEPARTMENT <br />� 32C� Cedar Sireet <br />Eetrett. WA 98201 <br />".iono�, 259�8815 <br />� -/� t3 � <br />,%f!^.Gci <br />ACKNOWL[OGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undcisigneA owner/applicant hereby ag�ees to hoiA and save harm� <br />Icss the City ef Everelt Irom any and all claims for tlamages, costs, <br />expenses. or causes ol action ihat may arise because ol installation <br />and maintenance ol Ihe improvement or olher right�of-way use hereto <br />applied lor and lurther agrees lo remove same upon notice Irom the <br />Cily and lo replace puUlic property dameged thereby. <br />z�_3ti-�.'�`�%% /.�i.r��.�-_ �/.�/�7 <br />Sionature ol Applicant 'Dafe <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />1B0 DAYS OF DATF PERMIT IS ISSUED AND THEREAFTER IS TO <br />8[ DILIG[NTLY PURSUED TO COMPLETICN. TI11S PERMIT MAV BE <br />CANCELIED BY THE GTY UPON ANY STOPP�G[ Or N'ORK OW THIS <br />PROJECT OVER 90 DAVS DURATION. <br />