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Date�lv��o � <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Address <br />Describe Proposed V:'�rk <br />Prolect Address (if known) `3Dp`3— <br />City <br />Attach four (4) copies of plans for proposed work - Draw to scale and note thP following as applicable: <br />• Property Lines <br />• Outline and dimens�ons of all existing and <br />p�oposed structures on the lot <br />• Exis�ing and proposed utilities <br />� <br />Pu�Iw Woiks Permi� v v —/�� <br />Bitlg. Depi. • � <br />PWIicWorksFee $ <br />Tol�l Fee _ <br />LessAap� FeePaN $ <br />Balance0ue $ ZQOO <br />• Centerline ol street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />Phone <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made : 1 hrs. in advance - phone 259-Fj810. <br />2. All work shall be Performed in �ccorda,ice wit��� ihis permit and curren: Jity of Evereti Design and Construction <br />Standards and Specificat�.�n.s. <br />3. Call Location Unde��jround Service 48 hrs. befo�e you dig. TOLL Ff EE NUMBER 1-$00•424•5555. <br />i1.1 f��nc-�-�� 3 -2S�-S8 <br />Approved for CoG��/ Date <br />" � f '�'i <br />FI AL INSPEC N Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone:259-BB70 <br />ACKNOWLEDIiEMENT OF CONDITIONS <br />� <br />W <br />� <br />� <br />� <br />� <br />� <br />a <br />The undersigned ownedapplicant here6y agrees to hold and save harm- ��, <br />less the City of Everett from any and al! claims lor damages, wsls. � <br />expenses, or causes ol action that may arise because of installa�ion <br />and maintenance of ihe improv�ment or other right•of-way use hereto <br />applied for and furth�r agrees to remove same upon notice trom ihe , <br />Ciry and to replace public property damaged ihereby. ' <br />�"In „ � n ., %� , . A � A . ' <br />d <br />ate <br />WORK AUTHORIZ[D BY iH�S PERMIT T 8E STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUE AND THEREAFTER IS TO <br />BE DILICL�iT�Y PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ; NY STOPPAGE OF WORK ON THIS �, <br />PFOJECT OVER 90 DAYS DURATIOh. , <br />