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Date�-� D <br />Applitalion F�r <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Maihng Address <br />Cdy <br />r�„nr�� w�ns r�,m� . �l�,y <br />om� o�m � y <br />aoebc warVe roo <br />Tatnl fae s <br />Lass Fonl Fee Pm0 S <br />�A��InCP Du9 S <br />�-�►�o �-�sr %�3� s. ������� ��,�►�� ��a�a �9y-qaS� <br />Applicant Mailing Address Clty Zip Phone <br />Describe Proposed Work <br />Project AdOress (il 4nown) <br />Attach four 1�7) copies of plans for proposed work - Draw to swle and note tne lollowing as apPlicable: <br />• Property Lines <br />• Outline and dimensions ol all existing and <br />proposed st�udures on the lot <br />• Existing and proposed u�ilities <br />• Centerline ol street <br />• Indicale Norlh <br />• Fhow any proposed grading changes <br />• S �w measurements <br />PERMIT CONDITIONS <br />1. All cells for inspection shall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shell be pertormed in acwrdance with this permit and current Ciry of Everetl Design and Construction <br />Standards and Specificetions. <br />3. Call Location Underpround Service 48 hrs. before you dig. TO�� FREE NUMBER ��800-424•5555. <br />� /��frvL �� .Ctl �.OL -G�al�: v' <br />/' <br />`F�" "- � �`%�Y,Lu�- <br />���/!�%�F� <br />����5%�� B <br />Approvetl for Construction Date <br />FINAL INSPECTION Date <br />Approvetl as Consiructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 9200 Cedar Street <br />Everett, WA 98201 <br />Phune 259�8810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />The undersic�ned owner/applicant hereby agrees to hold and save harm- <br />iess Ihe City ol Everett Irom any and all claims tor damages, costs, <br />expenses, or causes of aclion that may arise because ol installation <br />and maiMenance ol the Improvemenl or other righhohway use hereto <br />applicd for and lurther agrees to remove same upon notice from ihe <br />City and to replace pubhc p�operty damaged thereby, <br />Signature ol Applicant Date <br />WORK AUTHORIZ[D DY THIS PERMIT MUST BE STARTED WITHIN <br />1B0 DAYS OF DAT[ PERMIT IS ISSUED AND THEREAFTER IS TO <br />8[ DILIGENTLY PURSU[D TO COMPLETION. THIS PERMIT MAV 9E <br />CANCELLED BY THE CITV UPON ANV STOPPAGE OF WORK ON THIS <br />PROJECT OV[R 90 DAYS DURATION. <br />