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Date _ <br />Appiicalion Fo� <br />PUBLIC WORKS PERMlT <br />Print or Type Only <br />qpplicant <br />Describe Proposed Work <br />Prolect Address (il known! <br />M��hnq Address <br />Attach four (4) copies ol pians lor U�oposed wo:k � brav <br />• Property Lines <br />• Uutline and dimensions ol all existing anA <br />proposed slruclures on ihe Ipt <br />• Existing and proposed utililies <br />� <br />0 <br />� <br />O <br />� <br />a <br />O <br />M <br />IPuo4c Wor4a permll .—_ ��, I$f/.S'J Fi <br />eioq oco�. • �__ <br />FaObc Worhs Fee <br />Total cee S <br />Less aoo� �ce Va�a 5 <br />$ � � Baiance0uc S <br />M N M <br />M� M <br />� <br />� <br />O <br />;,ZiP <br />UW <br />S <br />l.l <br />Zip <br />to 5caie antl ncle Ihe loilowmg as applicabie: <br />• Genterline ol street <br />• Intlicate Norih <br />• $how any r,roposed 9rading changPS <br />• Sho�• measurements <br />Phone <br />u� rvvi wHi�t etlDW iH15 LINE <br />PERMITCONDITIONS <br />i. All calls for inspection shall be made 24 hrs. in advance • phone 259•8810. <br />2. All work shall be performed in accordance with this permit and current City of Everetl Design and Construction <br />Standards and Specificatlons. <br />3. Call Location Undergruund Senice 4B hrs. 6elore you dig. TOLL FREE NUMBER 1•800-424•5555. <br />� zo <br />�r�.,�:�� ��,�I) - �; ,.t. aCCPSS - <br />s� /�%'�c ,' � 2-o-Lv <br />arl�OS !1/-i2 <br />FINAL INSPECTION � Date <br />Approved as COnsirucled <br />�A��PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everet4 WA 98201 <br />Phone:259�8810 <br />W <br />� <br />_/ <br />� <br />� <br />♦�^ <br />V♦ <br />O <br />a <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undercianed owner/apphcxnl hereby agrees lo hold and save harm� <br />less the Gty o� Everett Irom any and all claims tor tlamages. costs. <br />e*penses. or causes of action that may aris^ because ol installation <br />and maintenance o! the improvement or other righFol�way use hereto <br />eppheC tor and lurther a9ree5 lo remove sane upon notice Irom Ihe <br />C�;y .�rd to replac:: pubhc proper;y damaged Ihereby. <br />,.�� �L � c� a.,2 9 <br />L� <br />Signal�ie of Applicant ate <br />WORK AUTHORIZEO BY THIS PERMIT MUST BE STARTED WITHIN <br />190 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUEO TO COMPLETION. THIS PERMIT IAAY 8E <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 �AVS DURATION. <br />