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Date���i_�,� <br />/ / Application For <br />PUBLIC WORKS PERMIT <br />Print or ?ype Only <br />Applicant <br />Describe Proposed Work <br />Project AAdress lil known) <br />� <br />Address <br />City <br />ruoi�c v�o�hs ve�mn . (�(- <br />eiap Den�. • !�� ��y�7 <br />Publ¢ WorFs Fee <br />Total Fec S <br />Less Apol Fee Peid S <br />Balance Due $ <br />�.T J .� co —J • � <br />ZiP Phone <br />l� ve �� 2-v( )� 74 7-856 � <br />z�P � � Phone <br />Atlach tour (4) copies ol plans br proposed work � Draw to scale and note the following as applicahle: <br />• Property Lines • Centedine of streel <br />• Outline and dimensions of all existing and • Indicate North <br />proposed SlrucW res on Ihe lot • Show any proposed c�rading chan�es <br />• Existing and proposed utilities • Show measuremeMs <br />PERMITCONDITIONS <br />1. All calls for inspection shall 6e made 24 hrs. in advance • phone 259•88� 0. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and S�ecifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800-424•5555. <br />� r'<-�'� l�>�� � �,u.�`/l�f <br />Approved lor Construction Date <br />FINAL INSPECTION Dale <br />Approved as Constructed <br />evereu PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Sirect <br />Everetl, WA 98201 <br />Phone:259�8870 <br />� � � 5���� <br />�'`"`` � <br />ACKIJOWL[DG[M[NT OP CONDITIONS <br />� <br />� <br />N <br />� <br />� <br />The undr.rsiqned ownedapplicant hereby a�rees lo hold and save hanm <br />Iess the Gty ol Everetl Irom iny antl all claims for dama�ec, costs. <br />expense5, or Causes of action Ihat may anse Uecause ol installa�ion <br />and maintenance ol the improvement or other n�hDobway use hereto <br />applied for and lurther a9rees to remove same upon nolice Irom the <br />City and lo replace puUlic properly damaqed IhereUy. <br />Sipnalurc ol Applicanl <br />WORK �UTIIORIZ[D BY TIi15 PERMIT MUST BE START[D WITHIN <br />180 DAYS OF D�T[ PERMIT IS ISSUED AND THEREAFTGR IS TO <br />BE DILIGENTLY PURSUED TO COIdPLEfION. THIS PERMIT MAV U[ <br />CANCELLED BY TI-16 CITY UPON ANY SIOPPAGf OF WOfiK ON TbIIS <br />PROJECT OVIif190 DAYS DURA7101J <br />