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Date��� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Mailing Address <br />Address <br />�escribe Proposed Work <br />Project Address (il known) � �'3 � � <br />City <br />% <br />�✓ <br />Puohc wo�6s Pcrmn <br />pWp pept • <br />Put�bcWorksFm $ <br />Total Fee <br />Lass Pop�� Fee ParA S�-- <br />Balnnce Oue <br />Zip Phone <br />Attach lour (4) copies ol plans lor propo��� work - Draw �o scale and nole Ihe lollowing as applicable: <br />• Property Lines <br />• Outline and dimensions ol all exisling and <br />proposed slructwes on �he lot <br />• Existing and proposed utllities <br />• Centerline of street <br />• Indiczte Nonh <br />• Show any proposed grading changes <br />• Show measurements <br />PERMIT CONDITION:: <br />1. All cails for inspecticn shall be made 24 hrs. in advance • phone 259•8810. <br />2. All work shall be perlormed in accordance with this permit and current Gity of Everett Desiqn and Construction <br />Standards and Speafications. <br />3. Call Location Under4iround Service 48 hrs. betore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />Q���D`� r / 1 /C�'J /�—%!r� / 8V <br />pproved 1� strucf n ate <br />/L� i � / ��1"(///.,� //� � <br />FINA–IN PECTION-l�� �7 Date <br />Approved as Construded � <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200CedarStreet <br />Everelt, WA 96201 <br />Phone:259�bB10 <br />ACKNOWL[DGEMENT Of CONDITIONS <br />� <br />� <br />� <br />� <br />Q <br />� <br />� <br />O <br />a <br />The undersigned owner/appliwnt hereby agrees to hold and save harm- <br />less the Ciry ol Everett from any and all claims tor damages, costs, <br />expenses, or causes ol action that may arise because of inslallation <br />and mainlena�ice ol lhe improvemenl ur other righ4ol-way use hereto <br />applied lor and lurther aqrees to remove same upon notice irom the <br />City and �o replace public property damaged thereby. <br />' 10 I I� 6 p <br />$tgRBtQre ol Applicanl Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />8E DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGc OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />