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� oete��L3/71g� <br />i <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />PuOpc Worka Permll • (O�� V <br />Blae. Oeol. r <br />Public Works Fee <br />Tatal Fee S <br />lass AoO� Fee Pai� S�!' <br />Balance �ue .S � V �' <br />7�l o � (p�O' <br />�vv���a��� nnamng qrldress Cit — <br />Y ZiP Phone <br />Prcject Address (if known) <br />Atlach four (4) copies of plans for proposei work • Draw to scale and note the following as appliczble: <br />• Property Lines <br />• Outline and dimensions of all existing and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />��s <br />PERMfT CONDITIONS <br />• Centedine of street <br />• Indicate North <br />• Show any proposed gradinc7 changes <br />• Show measurements <br />t. All call� fur inspection shall be made 24 hrs. in advance - phone 259-881 5. <br />2. All work shall be perfo-med 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 />���o� �i S��ci'6 <br />Approved for Constru ion —' <br />/ Date <br />��� � L'���- �- �i _�� <br />FINAC�NSPEC110N Dete <br />Appioved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98207 <br />Phone: 259-8815 <br />ACKNOWLEDGEIAENT OF CONDITIONS <br />� <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant hereby ayrees to hold and save harm• <br />less the City of Everett hom any and all claims tor damages, costs, <br />expenses, or causes ol aclion that may arise because of installation <br />and maintenance oi the improvemr.nt or other right•of•way use hereto <br />applied for and fwther agrees to remove same upon notice irom th�r. <br />City::nd t�'replace public property damaged thereby. _ <br />Signature of Applicant `� `� ate <br />WOFK AUTHORIZED BY THIS PERMIT MUST BE ST TE WITH:N <br />180 DAYS OF DATE PFRMIT IS ISSUED AND THEFEAFTER 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 />