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Date I7--21'-L38 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Public Works Permit <br />Bldg Dept a <br />Publ¢ Work$ ree S <br />Total Fee <br />Less spPl Foe Pa.d S <br />Balance Due $ <br />(IIY I r--vrlra-TT I'IY Nn.tL c-IG3 2ti`I-r+_P4Ri <br />Owner Mailing Address City Zip Phone <br />Applicant mailing Address <br />Describe Proposed Work <br />City �j� Zip PhoneMA <br />-A W <br />Project Address (if known) <br />Attach four (4) copies of plans for proposed work - Draw to scale <br />and note the following as applicable: <br />• Property Lines <br />• Centerline of street <br />• Outline and dimensions of all existing and <br />• Indicate North <br />proposed structures on the lot <br />• Show any proposed grading changes <br />• Existing and proposed utilities <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259.8810. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Constructio <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. re you dig. TOLL FREE NUMBER 1.800-424-5555. Gt <br />MUni�ipal bet - <br />Note 11 <br />each corrlc->r <br />Avnip,dar hizv. e""`x2_2'0 <br />1t' bC of:O API <br />NyC <br />^!c L29- <br />L d u.M,.pe.$a.� t� 3,a,PraQ4e�, •'� <br />App ved for Constructio f Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />Ever Cedar Street <br />Everett, WA 98:J1 <br />Phone: 259-8810 <br />". Je-fmore <br />bra 44 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />O <br />a <br />The undersign, jwner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages. costs. <br />expenses. or causes of action that may arise because of installation <br />and maintenance of the improvement or other right -of way use hereto <br />applied for and further agrees to remove same upon nonce from the <br />City and too replace public property damaged thereby. Gam, <br />Signature of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />