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Oate��a, <br />ApPlication For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />�� <br />[lescribe ProPosed Work <br />Proled AdAress (if known) <br />�`� <br />City <br />Zip <br />pobLc J:o�ks � etmi� • I C�L <br />Bldp Dept. � � / � ..L� ^ <br />Publ¢ \Ya�ke Fee S <br />Tolal F�o <br />Loas Appl. Fee Peid S <br />�nlenco Dua S <br />Attach fow �4) copies of ptans lor proposetl work - Draw to scale and note the foilowing as applicable: <br />• Property Lines • Centerline ol street <br />• Outline and dimensions ol all exisling end • Indicate North <br />proposed slructures on the lol • Show any proposed grading changes <br />• Ezisting and Vroposed utilities • Show measuremenls <br />Phone <br />PERMIT CONDITIONS <br />1. All cails for inst�ction shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All work shall be perlormed in accordance witn Ihis permit and current City o1 Everett Design and Construction <br />StanderOs and Specifications. <br />3. Cell Location Underground Service 48 hrs. Uelore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />�vB� �e �.��,�,�-.s <br />for Construction <br />��,FiniT it/0% <br />Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />evcrett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Stree� <br />Everelt. WA 90201 <br />Phone: 259�8815 <br />�(�Ec�Ur��.O <br />8�S"/87 <br />' .t�.,/.i <br />.� <br />ACKNOWLEDGEMENT OF CCNDITIONS <br />W <br />H <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owner/applicanl hereby agrees to hold and save harm- <br />less the City oi Everett irom any and all claims for damaBes, costs, <br />expenses, or causes of aclion that may anse because ol installation <br />and maintenance ot the improvement or other righPOFway use hereto <br />applied lor and further agrees to remove same upon notice irom the <br />Cily and to replar,e pubLc p�operty damaged thereby. <br />Signature of Applicant Date <br />�YORK AUTHORIZED BY TNIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTEP IS TO <br />8E DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCE�LED BY THE CITV UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />