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Date N" � � �� <br />qpplicatlon For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />V11116c Wm45 Pn�QT�I �� <br />B�np Oeo� � —.V_ <br />��„���,� w,,,,, � �� s <br />imai rca <br />�es. nnN ree rn�a S <br />o„a�r�r Du- S <br />Mailing <br />Describe Proposed Work ��r `� <br />C�tv <br />Prolect Adtlress lif knownl �' � '� ' ��"' " ' <br />Attech low �4) copies ol plans br proposed work � Draw to scale and nole the lollowing as �pplica6le�. <br />• Property Lines <br />• Outhne and dimensions ol all existing and <br />proposed ShuCtureS on Ihe IoI <br />• Ecisting and proposed utilities <br />• Centerline of sireet <br />• Indir,ate North <br />• Show any proposed grading chanqes <br />• Show measuremeats <br />PERMIT CONDITIONS <br />1. All calls for Inspection shell be made 24 hrs. in advance - phone 259•8810. <br />2, All work shell be pertormed in acwrdance with ihis permit and current Ciry ol Eve�ett Design and Consiruction <br />Standartls end Specilications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />y-,�-s�4 <br />l'o=�.alr �e:�Co f��a�.,� J�-��ti'�'/' �i� <br />��, �„�° �..� ,�.� � �� J��� � <br />� <br />,�� �2 tv�.�� .a/�.�z� : <br />Approved for Consiruction Date <br />FINAL INSPECTION Date <br />Approved as Gonstructed <br />everetl PUOLI,WORKSDEPARTMENT <br />� 3200 Cetlar Slreet <br />Everetl. WA 90201 <br />Phonc�.259�BB10 <br />ACKNOWLEDGEMEN' OF CONDITIONS <br />W <br />H <br />� <br />� <br />� <br />� <br />O <br />a <br />The undersignetl owner/applicant hereby a9rces to hold and save harm� <br />Icss the City ol Everelt Iwm any and all claims for damages, cests. <br />e�penses, or causes of adion that may arise because ol installation <br />and maintenance ol the improvement or othei righbot-way use hereto <br />apPlied lor anA �urther agrees to remove same upon notice Irom the <br />City and to rep�eace pul;hc pronerly damaged ihereby. <br />Si9nature of APM�cant Date <br />WOFiK AUTHOFIZ[D BV T1115 PERMIT MUST BE STARTED WITHIN <br />180 DAVS OF DAT[ PEFMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BF <br />C�NCELL[D 8Y THE GTY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />