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Date ///�N/� <br />/ � Applicalion For <br />PUBLIC WORKS PE!`MIT <br />Print or Typc: Only <br />�ddre55 <br />Mailinc 4dtlre.ss <br />ny <br />City <br />Describe Proposed Work _� � — h F�v�i 1(��P' � <br />Pro�ect Addiess (il knownl <br />����(� ✓ <br />PuOe[ WOrAf PnrmnC� .- .. ,�'�"�_. _ _ .. <br />oma oeoi. , —�3—C� /-q73,J,�5 _._ . <br />Pu�nc Wm�s Fee <br />inlal Fee $ — <br />Less 4n01 Foe Pm� $ <br />> rL- <br />e,i,���• o�., S 6 G _ <br />�i/ a.�.t- - d 7 <br />7ip Phone <br />Zip Phone <br />Attach lour (�) coPies o' plans for proposed work - Draw to scale and note the lollowing as apUlicable: <br />• ProCerty Lines <br />• OutGne and dimensions ot all e�isting and <br />proposetl 5lructures on ihe lol <br />• Existlng and proposed utilitles <br />• ('�enlerline of street <br />• Indicate Norih <br />• Show any proposed yratling changes <br />• Show measuremen�s <br />PERMIT CONDITIONS <br />1. All cells lor inspection shall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shall be pertormed i�i accorda�ce with this permlt and current City ot Everell Desi9n and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1-800•424•SSrJS. <br />Cn_�'CI <br />Io� R"oi,sy4ctio�� ua« <br />i �[��. <br />/'�'./"ir / � �-!7 ' i'� <br />FINAL INSFFCTION <br />Approved as Con,tructed <br />evcretl PUBLIC WORKS DEPARTMENT <br />� 3200 Cetlar SVeet <br />Lverett. WA 98201 <br />Phone:259�A810 <br />ACKNOWL[DG[MEN70F CONUIf10N5 <br />W <br />H <br />G� <br />� <br />O <br />�w <br />_/ <br />O <br />a <br />Thc untle�si9ned owneUapplicant hereUy aaree�� :o hold and save harm� <br />Iess Ihe Cdy ol Everett Irom any and all claims lor dama�es, costs. <br />e•penses, or causes ol action Ihat may arise Uecause of installation <br />and maintenance of Ihe impwvement or other righPof-way use hereto <br />applied lor and lurther agrees to remove same upon notice irom Ihe <br />City and to reolace pub ic pro )�rty damaged thereby. <br />%� ' ,�..�..-_ i - 3 0 - y� <br />ignalure of Applicant Date <br />WORK AUTHORI2ED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 D�YS OF DATE FERMIT IS ISSUED AND THEREAFT�ER IS TO <br />BE DILIGENTLY PURSUED TO GOMPLETION. THIS PERMIT MAY BE <br />CANCFLL[� BV THE CITY UPON ANY STOPPAGE OF WORK ON TNIS <br />PROJECT OVER 90 DAl'S DURATION. <br />