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oate�i �/ <br />�, <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />W� Il,p �,s 9.�8 - s� �'' s�- scJ <br />Mai4ing Address i <br />��. r✓`5t eoN3f. /U9z9 <br />Ap{ licant Mailing <br />r• Publro Wo•ks Peimit s /� <br />Blag. Ue01. s g�� � �j,�'!!7 � <br />Public WOMs Fee <br />To�al Fee S <br />Less NppL Fee Par� $ <br />Baiance Due S <br />9�Za3 259-�SDf� <br />2iP Phone <br />4zo�! 3�7 /5�9/ <br />Zip Phone <br />Des.rib+ProposedWork O� U9 ��/�y �iD,vl7/bN O(/IL.¢ EX/`�T�tiG /�TTNCypO CARRG�. <br />9Z8-S/�r St <br />Project Address (if known) <br />�tl <br />Attach four (4) copies of plans for proposed work • Draw to scale and note the following as applicable: <br />• Praperty Lines <br />• Outline and dimensions of all existing and <br />proposed structures on the lot <br />� Existing and proposed util�ties <br />• Centerline of street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measuraments <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259-8Ei1 5. <br />2. All work shall be performed in accordance with this permit and c�rrent City of Everett nesign and Construction <br />Standards and Specifications. <br />3. Call Location Undeiground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800•424•5555. <br />/"Ub'G/G� GC�C>�'�/°,-..5- �"E.�il�// <br />Approved for Construction Date <br />FINAL INSPECTION Date <br />Approved as Consiructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 38201 <br />Phone: 259-BB 1:i <br />iC/VT .C�EC�i.PEL7 <br />`•� 7/ 3/A6 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />O <br />The undersi�ned owner/applicanl hereby agrees to hold and save harm• <br />less the City of Fverett from any and all claims for damages, costs, <br />expenses. or causes of action that may arise because of installation <br />and maintenance ol the improvement or other right-of-way use hereto <br />applied tor and furiher agrees to remove same upon notice from ihe <br />City and to replace public property damaged thereby. <br />Signature of Applicant <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT �S ISSUED AND 'fHF.REAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELIED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />