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Dale�� ��������,w�,�.N��m�,�. �J�OZtry— <br /> oiaq oeN�•�-L)/C�L.c�� <br /> Applicatlon For <br /> PUBLIC WORK� PERMIT �°�°°°W°��,��° - <br /> .o�.�Fes s <br /> Less�nn� FeePua S <br /> eeixnce��e s <br /> Print or Type Only <br /> ` QW�e� Mailiny Addiess Cny Zin Phone <br /> ApplicaM Maihng AtlAiess City Zip Phone <br /> Descnbe Proposed WorK ��0� <br /> W <br /> Proiect Aatlress�il k owN � ���✓ ...�� � <br /> Attach lour(4� coples oi plans for proposed wo�k- Draw to scale�nd note Ihe I�Ilowing as applicable: � <br /> • Property Lines • CeMerline of sireet � <br /> • Outline and dimensions of all exisfing and • Indicate Norih <br /> proposed siructures on the lot • Show any proposed graAing changes <br /> • Ezisting and proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> t.A�I calls for inspection shell be made 24 hrs.in advance-phone 259•8810. � <br /> 2.All work shall be peAormed in accordance with ihis permit and current City ol E��erett Design and Construction <br /> Standards&nd Specilic;etions. <br /> 3.Call Location Undergrcund Service 48 hrs.belore you dic�.TOLL FREE NUMB@R 1•800-424•5555. � <br /> �'�T ��U1��0 ,,� � <br /> 9-is- �8 � <br /> � <br /> � <br /> a <br /> ACKNOWLEDGflMENT OF CONDITIONS <br /> 1 he unde�s�gned owner/apPlicant hereby agrees to hold and save harm� <br /> — iess th� City ol Everelt Irom any and all claims for damages, custs. <br /> eapenses, or causes of aclion that may aiise because of installation <br /> and maintenance of the imprcvemenl o� other right-ol�way use hereto <br /> applietl for and lurlher agrees lo remove same upon noiice IrOm ihe <br /> Appioved lo�Conslruction �d�� GIy and to rep�ace public property damaged iherehy. <br /> FINAL INSPECiION Date — <br /> Approved a5 Conslructed S�gnature ol Applicant Date <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everetl PUBUG WORKS DEPARTMENi 180 DAYS OF DATF PER�d1T IS ISSUED AND THE(iEAFTER IS TO <br /> � 3200CedarSireet BE DIUGENTLY PURSUED TO COMPLETION. THIS PEFMIT MAV BE <br /> Everett.WA 98201 CANCELIED BY THE CITV UPON ANV STOPPAGE OF WORK ON THIS <br /> pnone�.259�5810 PROJECT OVER 90 DAVS DUHAIION. <br />