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Date 9/G�lrTy <br />i <br />Applicalion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Mailing <br />Address <br />cuy <br />Zip <br />PubM1c Wods Pormil �" r LTp <br />oieq oco�.+ � � � <br />PubLCWorksfoo a <br />Tolol Fee — <br />I.ess PpPI. Fee Paitl $ <br />aa�e��a o�o s .2l� 00 <br />�� <br />Describe Proposed'�Vork <br />/� — <br />Prolect Address (il known) <br />Attach four (4) copies of plans for proposed work • Draw lo scale and nole lhe following as applicable: <br />• Property Lines • Centerline ot street <br />• Oulline and dimensions ol all exis�ing and • Indicate North <br />proposed struc�ures on ihe lol • Show any proposed grading changes <br />• Existing and proposed utilities • Show measuremen�s <br />PERMIT CONDITIONS <br />t. All calls lor inspection shall be made 24 hrs. in advance - phone 259-881 5. <br />2. All work shall be performed in accordance with ihis permit and current City ol Evere�t Desi9n and Consiruc�ion <br />Standards and Specilications. <br />3. Call Location Underc�round Service 4B hrs. belore you dig TOLL FREE NUMBER 1•800•424-Sb55. <br /><'�Af�,/'��i{Jij�9 ' //�/�� <br />Appr ed for Construction , Dale <br />in <br />Approved as Construcled <br />����i�� PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Sreet <br />Everelt, WA 9E201 <br />Phone: 259-8815 <br />Dale <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersi�ned owner/applicanl hereby agrees to hold and save harm- <br />less lhe City of Everett irom any and all claims for damages, costs, <br />expenses, or causes of action ihat may arise because of insta�lation <br />and maintenance ol the improvement or olher righl�of�way use hereto <br />applied lor an f�rther agrees to remove same upon notice from the <br />City and �o r ce pu li �perty damaged ihereby. <br />— ./I'✓L i' \CE / �/7�0 ` <br />�.SignaWreo PP���� � ate <br />WORK AUTHORI D BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSJED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COM'LETION. THIS PERMIT MAY BC- <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />