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Date <br />Appl�cation For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />vum�c ww�a vermrt • �� J`S� _ <br />8'da Depf � <br />PuolicWorFSFee a <br />Totel Fee <br />lenf /.oD� Fee PeiC s <br />B�Iance Dae � �D �[� <br />?����ln Z <br />f.f'/�/✓� I�F�_F //C/'L /67�'r/c.S.6 S/.�'.vr�x��N, i�f�'i'!I j'23'-c�3t3 <br />Owner Mailing Address Ciry 2ip Phone <br />S�VM C �7 _ <br />Applicant Mailina Address City Zip <br />Describe Proposed Work �<<�6 V � <br />NE <br />Project Address (if known) <br />Attach four (4) copies ot plans lor proposed work - Uraw to scale and note ihe following as appiicabie. <br />• Properry �ines <br />• Outline and dimensions of all existing and <br />proposed struclures on the lot <br />• Ezistinq anC proposed utilitie� <br />PERMii CONDITIONS <br />• Centerline ol 5treet <br />• Indiwie Nor�h <br />• Show any proFosed graAing changes <br />• Show measurements <br />Phone <br />1. All calls 1or inspeclion shail be made 24 hrs. in advance - phone 259•881 S. <br />2. All work shall be performed in accordance wifh this permit and current City of Everetl Design and �onslruchon <br />Standardc and Specilicalions. <br />3. Call Location Underground Service 48 hrs. before you tlig. TOLL FREE NUMBER 1•800•424•5555. <br />Approved tor Construclr6n ��� <br />���/ � -- ,3-„?7-d') <br />AL INSPECTIOtJ Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARiMENT <br />� 3200 Cedar Street <br />Everett. WA 98201 <br />Phonc 259�8815 <br />ACKNOWLE�GEM[WT OF COIJDITIONS <br />W <br />F- <br />� <br />� <br />Q <br />� <br />� <br />� <br />a <br />The unde�signed owneUapplicant hereby agrees tc hold and save harm� <br />less tPe City of Eve�ett Irom any and all claims lor damages, costs, <br />expenses, or causes of action Ihat may arise ber.ause ol installation <br />and mair,tenance ol the improvement or other righ�-ohway use he•eto <br />apP��ed lor and �urther agrees to remove same upon notice Irom the <br />Crty an6 to replace public property damaged thereby. <br />�o�.�_ ��-��-�y <br />Signa re ol Applicant Date <br />WOFiK AU7HORIZED BY THIS PERMIT MUST BE STARTED WITHItJ <br />180 DAYS OF DATE PERId1T IS ISSUED AND THERcAFT[R IS 1G <br />BE DILIGENTLY PURSU[D TO COMPLC110N. Th!IS P[HM17 MHV �[ <br />CANCELLED OY THE C.TY UPON ANY S1�iFPFGE OF �'✓ORK ON THIS <br />PROJCGTOA'LR'�D DAYS DURpTIGFi <br />� <br />f: <br />�� <br />ti� <br />�: <br />�' <br />�� <br />�] ' <br />�' <br />C: <br />� , <br />C <br />�' <br />r] ' <br />J <br />�t <br />� <br />� <br />Z <br />