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Date � i ri <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Po01ic Wqrks Permit • .Gf � <br />Bltlq Dept. s .: �� V <br />Pue�ic wmb Fea <br />Totol Fee s <br />Less ApP�� Fee Poitl S <br />BalanceD.�e S �� <br />1��aia ��/-��,E <br />nppiicant mtailing atltlress City Zip Phone <br />Project Address (il known) <br />Attach four �4) copies of plans for proposed work - Draw to scale and note the followin9 as applicable: <br />• Property Lines <br />• Outline and dimensions o( all existing and <br />proposed structures on the lot <br />• Existing =�nd proposed utilities <br />��L� <br />PERMIT CONDITIONS <br />• CPntedine of ;treet <br />4 Indicale Norih <br />• Show any proposed grading ch2ngos <br />• Show measurements <br />t. AI; calls for inspection shall be made 24 hrs. in advance - phone 259•8815. <br />2. All work shall be performed in accordance with this permit and ccrrent Ciry of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location ;Inderground Service 4B hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />���� /�.�-�� - 5� 5< <9G <br />Approved lor Construction �ate <br />"��- % � <br />1�' l�/�� /= ��- �� <br />FINAL INSPECTION � Date <br />Approv?d as Constn��ted <br />�rveren PUBLIC WORKS DEPARTMENT <br />�3[00 Cedar Sireet <br />� Everett, WA 982G1 <br />Phone: 259�8b15 <br />1CKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm• <br />less the City ot Everett from any and all claims for damages. costs. <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice irom the <br />City and to replace public property damaged thereby. <br />��"� � �L �h�-�'`� <br />Signatureof� plicant Date <br />V�ORK 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 B1' THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />