110 50TH ST SW 2016-01-01 MF Import

�; ; a f. ( : E': �e l� t: Date h � � � 3 Application For PUBLIC WORKS P�RM17 Print or Type Only PuOb< Wo�ks Permit r �—�� eiae oeo�.. y !`�_ �� G� . Publ¢ WorMs Fee $ Tatal Fee less AOP� Fee PaiC $ _ Balance�ue $ �O� .-1r� �_� Phone Applicant Mailing qddress City Zip phone Project Address (if known) Attach four (4) copies of Vlans fo� proposed work - Draw to scale and note the following as anPlicable: • Property Lines � Centerline of street • Outline and dimensions of all existing and • Indicate North . proposed structures on the lot • Show any proposed gradinc� changes • Existing and proposed utilities • Show measurements PERMIT CONDITIONS 1. All calls for inspection ,hsll be made 24 hrs. in advance • phone 259•881 O. 2. All work shall be pe�formed in accordance with this permit and current City of Everett Design and Construction Standards and Speufications. 3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. Approved tor Approved as Consiructed everett PUBLIC WORKS DEPAqTMENT � 3200 Cedar Sireet Everett, WP. S8.'.01 Phone:253•0810 W H � � � O H � O a ACKNOWLEDGEMENT OF CONDITIONS The undersigned owner/applicant hereby agrees to hold and save harm- less the City ol Everett Irom any and a�l claims (c: damages, costs, expenses, or causes of action that may arise because of installation and ��naintenance of the improvement or other right-ohway use heieto a�plie for and further agrees to remove same upon notice from the City to replace pu c property dam ed�t,ereby. t ,� c��/�� ,? /1 %�%// i //'� Silnature ol Appl� ant Date WORK AUTHOR ED BY THIS PERM MUST BE STARTED WITHIN 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO BE DILIGENTLY PURSUED TO COMPLETIOtJ. THIS PERMIT MAY BE CANCELLED BY 7HE CITY UPON ANY STOPPAGE OF WORK ON THIS PROJECT O`/ER 90 DAYS DURATION.