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Date <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Public Works PermCC�ltt - <br />Bldg. Dept. <br />Public Works Fee $ <br />Total Fee <br />Leta Appt Fee Paid $ <br />Balance Due $ <br />11ffa„1 ,f f r,��( s4g gge �-, 1-43�5 f <br />Owner ' M fling Address City Zip Phone <br />f5ome <br />Applicant -'7-� Mailing Add—r�e-s-s / City Zip Phone <br />Describe Proposed Work <br />_ �I W <br />Project Address (if known)=�i�-"-"qi�LFI��`i ��V� <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements M <br />DO NOT WRITE BELOW THIS LINE O <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259.881 5. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1.800.424-5555. <br />P(/BL!G Cuot'.�' /�F.einiT it/OT iQEGfU/.PE.O `—�� O <br />CIO <br />.s/S/r97 <br />�,C' ij f'n l/i2�d /��,�ir✓�- �til� L y.,�OSC�'�'•��`.. a <br />ACKNOWLEDGEMENT OF CONDITIONS <br />T'.e undersigned owner/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 notice from the <br />Approved for Construction Date I City and to replace public property damaged thereby. <br />FINAL INSPECTION Date <br />Approved as Constructed Signature of Applicant Date <br />everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED UY THIS PERMIT MUST BE STARTED WITHIN <br />3200 Cedar Street 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMI-i MAY BE <br />Everett, WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />i <br />Phone: 259.8815 PROJECT OVER 90 DAYS DURATION. <br />