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Date`,�"�T _ <br />Application For <br />PUBLIC WORKS PERMIT <br />Pv0licWa�ksPermi�+ �� /� <br />eia9. oeo�.• � <br />Pu01ic WorksFea $ � �+ J � <br />Tolal Fea � �=� <br />Less PpO� Feo Paid $ � ^ <br />0alanceDue s r' �� <br />Prinf or Type Only (. u`�� <br />� � / <br />/ / i <br />� L,[.fl� �ll� �»7<l �L-� �� 3 � .c �,—r...� �r� � �� i i� s ;� �'y � � <br />cu� Zio Phone <br />Project Address (il known) � — — <br />Attach lour (4) copies ot plans for proposed work • Draw to scale and note the tollowing as applicable: <br />• Property Lines <br />• Outline and dimensions o� all ezisting and <br />proposed strucWres on lhe lot <br />. • Existing and proposed utilities <br />• Centerline ol street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measuremenls <br />PERMIT CONDITIONS <br />1. All calls lor inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All worh shall be perbrmed in accordance with lhis permit and current City ol Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location UnAerground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800-424•5555. <br />a�-,r; <br />Date <br />FINAL INSPECTION <br />Approved as Constructed <br />everelt PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everet6 WA 98201 <br />Phone: 259-BB15 <br />uate <br />ACKNOWIEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />N <br />� <br />O <br />� <br />N <br />O <br />a <br />1 he undersigned owner/applicant hereby agrees to hold and save harm� <br />less the Cily of Everett Irom any and all claims for tlamages, cosls, <br />expenses, or causes of action that may arise because ol installation <br />and aintenance ot ihe improvement or other right�ol-way use herelo <br />app ed for and lurther �rees to remove same upon notice Irom the <br />C ar}d to replace pub c p oPerty damaged thereby. <br />� <br />� , , <br />. <br />Signature f 'cant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMiT IS ISSUED AND THEREAFTER IS TO <br />8[ C�ILIGENTLY PURSUED TO COMPLETION. THIS PERMIT �1AY BE <br />ChNCELI.FD BY THE GTY UPON ANY STGPPAGE OF WORK ON THIS <br />PRO,IECI"OVER 90 DAYS DURATION. <br />z <br />0 <br />-i <br />c� <br />m <br />� T <br />..� <br />�, _ <br />m <br />co <br />m o <br />--i c <br />0 3 <br />m <br />�z <br />m � <br />.o z <br />c <br />a� <br />r =c <br />�. <br />-i tn <br />< <br />� <br />O D <br />� m <br />x <br />m � <br />� <br />0 <br />o r <br />c� m <br />c v+ <br />' N <br />m' <br />z c� <br />-i r <br />. "'n <br />z <br />� <br />_ <br />� <br />Z <br />� <br />_ <br />� <br />Z <br />0 <br />� <br />� <br />m <br />