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Dater <br />r_7 Application For <br />PUBIC WORKS PERM(T <br />Print or Type Only <br />errs' �i <br />�U ALf)y!&:V'V $► oft r//E-rty -rr <br />Owner Mailing Address <br />UJI <br />/tJ c' ro�� 7` <br />Applicahe Mailing Address City Zip Phone <br />J f ,✓ f <br />Describe Proposed Work / ! C-� 02 xr-1-04 e la CE j2Ar-o nd Ylze <br />r- 'e lwk it, h QC1 G 4::1V110( t V dpt W11150 Q St"�' li e s k k U&C <br />Public Works Permit #y5...�i <br />Bldg. Dept. # <br />Public Works Fee <br />Total Fee <br />Less Appl. Fee Paid $ 0 <br />Balance Due $" " <br />City Zip Phone <br />R <br />Project Address (if known) <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />DO NOT WRITE BELOW THIS LINE <br />PERMIT CONDITIONS <br />1. 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 Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800-424-5555.' <br />r, <br />"X— 4 / <br />Approved for ConstructionDate <br />FINAL INSPECTION Date <br />Approved as Constructed <br />i <br />PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-8810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages, costs, <br />expenses, or causes of action that may arise because of igstallation <br />and maintenance of the improvement or other right of waf'tise hereto <br />applied for and further agrees tb remove same 4upon :nIotice from the <br />City and to replace public property damaged thereby. <br />Signature of Applicant .' Date <br />WORK 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 COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />