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Date 5 -'� 1- � � <br />qvplicacion For <br />PUBLIC WORKS PERMIT <br />Prfnt or Type Only <br />r�oim wo�w� PP3• � �J J� % % <br />Blap. Dept � s1�—���—T <br />PubLC WOd�Fne s _— <br />Tol�� Fee <br />Leu �DD� Fee PeiE 5�� <br />B�bnce Due � <br />Malling <br />Describe Proposed Work <br />Prolact Address (il known) ' — � <br />A�tech four (4) coPies of plans lor proposed work - Draw to scale and note � CQ^I,ewi�e ol stree1 able: <br />• Property Lines • Indicate North <br />• Outline antl dimensions of all exisling and � ghow any proposed grading changes <br />proposed siruclures on �he lot � Show measurements <br />• Existing and proposed utili�ies <br />PERMIT CONDITIONS <br />i. All calls tor inspection shall Ae made 24 hrs. in advance - Phone 259•881 5. <br />2. All work shall be performed in accordance wilh this permil and current City of Everett Design and Construclion <br />S!andards and Specifications <br />3. Call Location Underground Service 48 hrs. hefore you dig. TOLL FREE NUMBER 1•800•424-5 . <br />�� <br />l� � i`� <br />� <br />�e� <br />� <br />ACKNO\VLEDGEMENT OF ;ONDITIONS <br />�� <br />2ls <br />u, 2�J� <br />�s <br />Date <br />Approved lor Construclion <br />Date <br />FINAL INSPECTION <br />Approved .+� ��orstructed <br />Oeverett FUBLIC WORKS DEPARTMENT <br />3200 Cedar Stree! <br />Everett, WA 9tl201 <br />Phone�. 259�BB15 <br />���� <br />f zZ-� <br />W <br />H <br />� <br />N <br />� <br />0 <br />� <br />� <br />0 <br />a <br />The undersigned owner/applicant hereby agrees to hold and save ha�m� <br />less Ihe City ol Everett trom any and all claims lor tlamages, cosls, <br />eapenses, or causes ol action ihat may arise because of installation <br />and maintenance of lhe improvement or other nghbof�way use herelo <br />applie0 lor and Wrther agrees to remove same upon notice Irom the <br />Cih� and lo rep�ace Public p�oPe<<Y damaged thereby. <br />— Datc <br />Signature o� Applicant <br />1v80RDAVSTOF DATE PERMTSISESSUED ANDBEiEREAFT�ER ISkTO <br />BE DILIGENTIY PURSUED TO COh1PLET�ON iHIS P[RA11i t•1NV E�E <br />CANCELLED BY THE CITY UPON nNY STOPDAGE OF \40RK ON TnIS <br />PROJ[GT OVEf7 90 D�YS DUR�TION. <br />� <br />[' <br />