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� <br />Date�i.�.J� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Zip <br />Publ¢ Wo�Ms Pcrmil " —�� � <br />eiaa o�o�. • �� <br />Publ¢ WorkS Feo 4 <br />To�al Fec <br />LP55 Appl PoC PB�O $ <br />Balan<a Due � <br />Describe Praposed Work <br />Prolect Address (il known) <br />Attach tour (4) coVies ol plans for proposed work- Draw to scale antl nole the folloe:��g as applicable: <br />• Propefty Lines <br />• Outline and dimens�ons ot all existing and <br />proposed structures on ;he lat <br />• Existinq and proposed u�ilities <br />• Centedi ie ot slreet <br />• Indicate North <br />• Show aa; prcp�„ed grading changes <br />• Show mcas.:��m�nis <br />PEI .�: !? CON�ITLJNS <br />1. All calls for inspection a�hall be made 24 hrs. in advance - phone 259•8610. <br />2, All work shell be peAormed in accordance with Ihis permit and current City ot Everelt Design and Construction <br />Stendards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•'324-5555. <br />%�'/'�..� -7/�/�� <br />ucJion Date <br />Date <br />Approved as Consiructed ( <br />evere[t PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 90201 <br />Phon¢ 259�8810 <br />ACKNOWLE�GEMF IT OF CONDITIONS <br />� <br />�J <br />� <br />� <br />O <br />a <br />The undersigned owneVapplicant he�eby agrees ro hold and save harm- <br />less ihe City ol Everett from ai�y am� all claims for damac�es, cosls. <br />expenses. or causes of aclion that may arise because ol installation <br />and maintenance ot the improvrr�ent or other righl-of-way use hereto <br />applied for and lurther agrees W remove same upon notice Irom the <br />City a d lo replace public property damaged thereby. <br />1 <br />/«G�,� ��- �/��� <br />Signature ol Applicant Date <br />WORK AUTHORIZtD BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSI�ED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY 8[ <br />CANf•ELLED BY THE CITY UPON AN� STOPPAGE OF WORK ON THIS <br />PqOJECT OVER 90 DAYS DURATION. <br />