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oate�%Q) <br />� � <br />� <br />App�ication For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Owner <br />Mail;ng Address <br />Cily <br />City Zip <br />Pu��2 wo,xs Per/m�it • / 6 <br />8�49 �ePi • l /�z—{�6 � i� <br />Puelrc Works Fee <br />10181 I!< 't <br />Less �04� Fee PeiJ f <br />BelenceDuP i <br />Describe Proposed Work _ ,�cg ��Q'���f��(,� (�Qj.(��. �C�/ 1� /�� '� a��� <br />Project Address lif known) <br />Attach four (4) copies ol plans for proposed work � Draw to scale and note the lollowing as apPlicable: <br />• P� operty lines <br />• Outline and dimensions of all existing and <br />proposed structures on the let <br />• Existing and proposed utilities <br />• Centerline ol sireel <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measuremenis <br />rnone <br />PERMIT CONDITIONS <br />1. All cells for inspection shall be made 24 hrs. �^ advance - phone 259•8810. <br />2. All work sheil be pedormed in ascordance with ; his permit and current City of Everett Design and Construction <br />Standerde and Specifications. <br />3. Call Location Un�erground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800-424•5555. <br />� /�<< ��,��� �.�.,,u�f � �-�' <br />� ���� <br />�i� <br />Approved for Construction Date <br />FINAL INSPECTION Date <br />Appraved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Sireet <br />Everett, WA 98201 <br />Phone:259-8810 <br />/1 <br />�' /''C" �I <br />�`� ��iG`, � � <br />h 1i� <br />�KNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />�J <br />I ne unaersignetl owner/applicanl nereUy agrees to holtl a�tl save harm� <br />less the City ol Everett Irom any and all claims for damages, costs, <br />expenses, or causes ol action that may arlse because ol instellation <br />and maintenance ol the improvement or o�her right-ol-way use hereto <br />apphed lor and further agrees to rr.move same upon notice Irom the <br />City and to replace public property damagetl thereby. <br />Signaiure of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE P�AMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED 8V THE CITV UPON ANY STOPPAGE OF WORK ON THIS <br />PROJE�T OVER 90 DAYS DURATION. <br />