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���i,I <br />Date�J-�� <br />� <br />Applicalien For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />��y <br />� � � r„ni�c wo,4s v.�, - <br />����� <br />oinq oeo� • � - - <br />{�Y111iL WC�45 FCU <br />tatni Fce s — - <br />�vssnm�i fer na�a � <br />e:��.,��:� n��,. S <br />z�n <br />Applicant Mailing Adtlress Ciry Zip Phone <br />Descnbe Proposed Work <br />Prolec� Addres5li� known) <br />A��aCh four 14) topies ol Plans lor proposed work � Draw to Scale and note �he tollowing as appllcable: <br />• ProPerly Lines <br />• Outline and dimensions ol all existing and <br />proposed siructures on the lol <br />• Existing and proposed utilities <br />• Centerline oi siree� <br />• Indicate Norih <br />• Show any proposed grading changes <br />• Show measuremenls <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 pertormed in accordance with this permil and current City of Everett Design and Constructior <br />Standards and Specilications. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1-500•424-5555. <br />�_!�[��L<<` �[c??i't���i��J)n�l�:c���Z f—['.i;cY?.�/� <br />�� <br />Approved lor Construclion Date <br />FINAL INSF'ECTION Dale <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everet4 WA 99201 <br />Phone::59-8810 <br />� �-i 3�ij 7 <br />��O. /� <br />�/ ,' � /)->C•` ��%� <br />i� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm� <br />Iess ihe City of Everetl irom any and all claims lor damages, cosis, <br />eaPenses, or causes of action that may arise because ol installation <br />and maintenance ol ihe improvement or o�her right-ol•way use hereto <br />applied for and furlher agrees to remove same upon notice from ihe <br />Cito and to ieplace pubhc property dama9ed Ihereby. <br />Siynatmc ol Applicant Dat� <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIG[NTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAVS DURATION. <br />