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Date�a��9� <br />Appliwtion For <br />PUBLIC WORKS PERMIT <br />Print o� iype Only <br />� `�Q�3 �U <br />Mailing Addrnss <br />P��.� wa,,,PP.m„. 9n - ys � <br />B�co �cot • <br />FuLhcWorbfee S <br />� otal Fee <br />Less A00�� Fee Pai� $ �j <br />Balan[e Due u C�— <br />S/� i Yl � <br />qpplicant Mailing Address CiD• Zip Phone <br />Describe Proposed Work � e�r <br />Pron� �-��(YI�� �1 <br />Frolect Address (if hnown) <br />�►�'lain-4�c.��n I5� x �'-��' o� Ci�� <br />Attach four (4) copies oi plans lor proposed work � Draw to scale and note the following as applicable: <br />• Property Lines <br />• Outline and dimensions of all existing and <br />proposed structures on the lot <br />• Existing and proposed ulilities <br />• Centeiline ol s�ree� <br />• Indicale Noith <br />• Show any proposeA gradinc� changes <br />• Sl��ow measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance- phone 259•SBiO. <br />2. All work shal: be perlormed in accordance wi�h ihis permit and current Ciry ol Everelt Design and Conslruclion <br />Standards and Specilications. <br />3. Call Location Underground Service 48 hrs. belore y�u dig. TOLL FREE NUMBER 1•8�•424-5555. <br />7. /�iiS�n�•7� if �r Clc�r��� ayr �roS� nn�j�lo�os/90 i:01PM OOOAq3974 <br />� <br />�(%O f/"C6S 4I'G o Lo /�inC✓��l / <br />N(1004177k <br />S. f%n� e,xcess �rvL,:+q a{' fi/�e qr�es. i»a�/pprl�gtui�t2o.00 <br />� C C{, ��ii?0.00 <br />CrcS�cn CCh-fr�l I'�'le�'/cdS 4S ciii-NC7�Co� �y <br />G��`PuGlic r.�rT�•fJ i�,s�[c�or � IC. � i.�st�al(�f.on <br />cf' Q S��Cf 7�'ncc� ��ii-�;c,'nJ � CfC•) <br />� �� /���� <br />���,� <br />Approved br Constr ion , ate <br />���.G�� � , :: - � � j c) <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar SVeet <br />Everelt, WA 98201 <br />Phone:259-8810 <br />ACKNOWLEDG[MENT OF CONDITIONS <br />W <br />� <br />� <br />The undersigned owner/applicanl hcreby agrees to hold and save harm� <br />less ihe Ciry ot EvereU Irom any and all claims for dama9es, costs. <br />expenses, or ca�ses ol action Ihat may arise because ol inslallaUon <br />and maintenance o( Ihe improvement or ather �ight-ot-way use hereto <br />applied for and luriher ayrees to remove same upon notice Irom ihe <br />City and to replace pul�hc property damaged Ihereby. <br />Signa`�ure of ApPlicant ua�e <br />�"lORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPI.[TION. THIS PERM1IIT MAV BG <br />CANCELLED BY THE CITY UPON ANV STOPPAGE OP WORK ON THIS <br />PRGJECT OVC-R 90 Di1V5 DURATION. <br />