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Date is a�G <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Zip <br />Public Wort" Permit a <br />Bldg. Bert+ <br />Public Wor%s Fee S <br />Total Fee <br />Less APPt Fee Paid <br />Balance Due S — <br />/mil-2�niT SEE To <br />Phone <br />Applicant <br />Mailing Address City Zip Phone <br />W <br />Project Address (if known) —,r C✓ y - �� J2 Giw �'Y rda S62•• 3 -- <br />Attach lour (4) copies o1 plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <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 <br />O <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259.8815. <br />be in accordance with this permit and current City of Everett Design and Construction <br />2. All work shall performed <br />Standards and Specifications. <br />3, Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1.800.424.5555. <br />O <br />Y i <br />O <br />a <br />ot-;>Ld <br />Approved for Construction A ate <br />Date <br />Approved as Constructed <br />i <br />PUDL;C WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259.8815 <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 public property damaged thereby. <br />t/ / ,� it <br />Signature of Applicant Date <br />WORK <br />AUTHORIZED <br />DATE PERM T ISPERMIT <br />ISS ED AND THEREAFTER ISWITHIN <br />180DAYS OF 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 />