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Date -/�' �9 <br />Application For .,o <br />PUBLIC WORKS�PERMIT <br />Q <br />O <br />� <br />O <br />Print or Type Only <br />Owner <br />Describe Proposed Work <br />Prolect Address (if known! <br />L O O <br />a <br />� o0 <br />ln CJ CJ <br />iR i1T <br />P <br />��� �/sj� PL.S.W. �V <br />Mailing Ad�s� ,r'„� o �� C�ry <br />.ti O • U <br />C�l O {— W <br />9., � �i'm7' � ,ty.r...w � <br />Mailing Address City <br />Zip <br />Attach four (4) copies oF plans tor proposed work - Draw to scale and note the following as applicable: <br />• Properry Lines <br />• Outline and dimensions of all existing and <br />proposed structures on the lot <br />• • Existing and proposed utilities <br />Pubi¢ Wo�Ms Permn � �/ 9 �� <br />eiay. oro�. , — - <br />PebLr. Wo�ks fce � <br />To�al Fe� <br />Less Apol. Fee Paia $ <br />9alance Doc $ ��— <br />• Centerline of street <br />• Indicate Nonh <br />• Show any proposed grading changes <br />• Show measurements <br />> ..3cJO <br />Phone <br />. PERMIT CONDITIONS <br />7. 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 Ciry of Everett Design and Construction <br />Standards and Specifications. <br />� 3. Call Location Underground Service 48 hrs. before you di9. TOLL FREE NUMBER 1•800•424•5555. <br />Approved as Constructed <br />everet[ PUBLIC WORKS DEPARTMEN7 <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-8810 <br />-3�/ <br />ACKNOWLEDGEMEN? OF CONDITIONS <br />W <br />H <br />� <br />� <br />O <br />� <br />� <br />0 <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm� <br />less the City of Everett from any and all claims fer damages, costs, <br />expenses, or causes ol action that may arise because o( installation <br />and main�enance of �he improvement or other righbof-way use hereto <br />applied lor and turther agrees to remove same upon notice irom lhe <br />City and to replace putGc prop2rty damaged thereby. <br />2^/� �8'% <br />5ignature of Applicant ^ Date <br />WORK AUTHORI2ED BY THIS PERMIT MUST BE STARTE� WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIuE�dTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 9C DAYS DURATION. <br />