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Date��� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />('�, _ ���� � <br />Owner MailingAddress City <br />I��Cv <br />Applicant Mailing Address Gly <br />Describe Proposed Work >� / "' "�z� -- <br />Project Addre55 (i� known) ��( Q � ` � ��� <br />z�� <br />Attach lour (4) topies of plans lor proposed work - Draw to scalq and note ihe lollowing as applicable: <br />• Property Lines <br />• Outline antl dimensions of all existing and <br />proposed strudures on ihe lol <br />• Exis�ing and proposed utililies <br />Pubbc Workn P �t • <br />eiee oem. � �� <br />Pu�lic WorFe Fee s <br />Totel Fce <br />Less ADGI. Fee i��iJ S <br />Oaien<e Due S <br />• Centedine ol sireet <br />• Indicate Norih <br />• Show any proposed grading changes <br />• Show measuremenls <br />�/—�jc��D <br />Phone <br />DO NOT WRITE BELOW THIS LINE � .., w <br />PERMIT CONDITIONS ,�. ��iT`. � <br />t. All calls for inspection shall be made 24 hrs. in advance � phone 259�881 5. <br />2. All work shall be perlormed in accordance with Ihis pennit and current City ol Everetl Design and Construction <br />Standards and Spec�liwtions. , <br />3. Call Location Underground Sdrvlce 48 hrs. before you dig. 70LL FREE NU65BER 1•800•424•5555. <br />� f�d�Gi c l�o,c',��s <br />Approved for Construc6on Date <br />FINAI INSPECTIJN <br />Approved as Constructed <br />cvrrett PUBLIC WORRS DEPARTMENT <br />� 3200 Cedar Street <br />EveretL WA 98201 <br />Phone:259-BB15 <br />�r=,�i». T <br />���(�/�t " <br />/ �� <br />� <br />/,�� <br />ACKNONLEDGEMENT OF CONC�ITIONS <br />L� <br />♦�^ <br />V/ <br />� <br />a <br />The �mders�gned own� UapP�icanl heieby agiees to hold and save harm� <br />less ihe City of Everetl Irom any and all claims lor damages. costs, <br />eapenses, or causes of action tha� may arise because o� installation <br />and main�enance of ihe improvement or other righbol�way use hereto <br />applied lor and lurther agrees to remove same upon notice Irom Ihe <br />City and to replace public property damaged thereby. <br />SignaWre ot AOPlieant uaie <br />WORK AUTHORIZED BY Ti11� PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DAT[ PERMIT IS ISSUEC� AND THEREAFTER IS TO <br />BE DILIGENTLY PURSU[D TO COMPLETION. TIiIS PERMIT MAY BE <br />CANCELLED �Y THE GTY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />