Laserfiche WebLink
�—Z�''—�F <br />-A <br />Datc _ — <br />� Application For <br />PUBLIC V�IORKS PERMIT <br />Print or Type Only <br />. <br />ow�e� '� <br />Address <br />��ir£ <br />Applicant M'�ding Adtlress <br />�escribe Proposed Work <br />Proiect Address (if known) <br />c�iy <br />r �C <br />8G - t:9S <br />PioLc woixs Permn . <br />BIEp Oen�. � <br />puencworxsFea s <br />To�elFea <br />Less Pppi. � ee Pa�d S L O� <br />Balan<e Oue $ - <br />s a -CS <br />Attach four (4) copies ol nlans for proposed work � Draw to scale and note the foliowing as appllcable: <br />• Property Lines <br />• Oueline and dimensions of all existing and <br />proposed siructures on the lo� <br />• Eristing and proposed utilities <br />• Centedine ol sireel <br />• Indicate North <br />• Shnw any proposetl grading changes <br />• Show mcasuremenis <br />FERMIT CONOITIONS <br />1. All calls lor inspection sha�l be made 24 hrs. in advance - phone 259-881 5. <br />2. All woik shall be perlormed in accordanr= with ihis permit antl current City ol Ev�rett Design and Construction <br />Standards and Specilications. <br />3. Call Location Underground Servlce a8 hrs. Uebre yeu dig. TOLL FREE NUMBER 1-800•424•,ri555. <br />�r/, %� � <br />.�. ��a�_ <br />Apnroved lor Co6struction� Date <br />��iPi �"�`i� -. . / � � /-�- <br />FlNrtt INSPFCTION Date <br />Aporo�eJ as Constructed <br />everett PUBLIC WORKS DEP.4RTMENT <br />� 3200 Cedar Street <br />Everetl, WA 98201 <br />Phone:259�8815 <br />W <br />H <br />� <br />� <br />O�i/24/is5 3�42Ph O�AMO688 #:� <br />ACKNOWLEOG�T OF C�D�ONS <br />Tne undersioned owncr/applic�reby a�.)�S�F ��old and save harm- <br />less ihe City o( Everelt Irom any end all cfaims for damayes. costs, <br />expenses, nr causes of action Ihet may arise because ol installation <br />and maintenance of Ihe improvement or olher righ4ubw�y use here;o <br />applied for and furiher agrees to re ve same upon notice irom Ihe <br />Ciry and to replace public property da�aged thereby. <br />�—� , - ' <br />n ,�, <br />�( [' -�-�-�ei �1` �� ��a���� <br />Sfynature ol'Appllcant ' �� j Date <br />WORK .4UTHORIZEU BY THIS PEi4MlT MVST BE STAFTED Vi1THIN <br />180 DAY3 OF DATE PERMIT IS ISSUED �ND THEREAF7�R IS TO <br />BE DILIGENTLV PURSUED TO COMNLETION. THIS PERMI �"�AY BE <br />CANCELLED BY THE GTY UPON ANY STOPPAGE OP WORK UN THIS <br />PROJECT OVflR 90 DAYS DURATION. <br />