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Dat , 3 � • <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Pu�lic Works. armit • <br />Bltlq.pepL • <br />Pu01m Warks Fee S <br />Totel Fea <br />Less ApO� Fee PeiE S <br />Balance Due S <br />��B �L�npNeG� 7Z5 oq« E,cf��7f� 95201 ?a5 - 9 s9 L <br />Owner Mailing Address City Zip Phone <br />Maumg naaress <br />l:vy up <br />Describe Proposed Work �U � L-l7 � A t`P ���' <br />Project Address (ii known) <br />Attach four (4) cepies ot plans tor proposed work - Draw lo scale and note the lollowing as appiicable: <br />• Property Lines <br />• Outline and dimensions ol all ezisling and <br />proposed structures on Ihe lot <br />• Existing and proposed utilities <br />• Centedine ol slreet <br />• Indicate Norih <br />• Show any proposed grading changes <br />• Shaw measuremenis <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be maAe 24 hrs. in advance - phone 259•88� 5. <br />2. All work shall be pe�formed in accordance with this permit and current City ol Everett Desiyn and Consiruction <br />Standards and Specilications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE N�JMBER 1•800•424•5555. <br />� ;!��% TL'�-'G-iG LGiniE'.f� <br />Approved lor Consirudion Date <br />FINAL INSPEGTION <br />Approvetl as Consiructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everet�, WA 98201 <br />Phone: 259•8815 <br />Date <br />j��l/"'/'-%% <br />�" v <br />�J[:l <br />�CFC�`lGi�/��. <br />/�- �/-�ys <br />ACK�OWLEDGEMENT OI' CONDITIONS <br />W <br />H <br />� <br />The undersigned owner/applir,aM hereby agrees to hold and save harm• <br />less the Ciry of Everett hom any and all claims lor damages, costs, <br />expenses, or causes ot action that may arise because ol installatlon <br />and maintenance ol the improvement or olher righPobway use hereto <br />applied for and further agrees to remove same upon nolice from ihe <br />City and to replace public property damaged thereby. <br />Signature �t Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BF STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND iHEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLE710N. THIS PERMIT Ml,V BE <br />CANC[ILED BY THE CITY UPON HNY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DUflATION. <br />