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Date�L!� <br />:� <br />AppliCa�ion I=or <br />PUBLIC WORKS PER�VIIT <br />Print or Type Only <br />Owner <br />Mailing Address <br />Describe Proposed Work 1.�L JC�� <br />Proiect Address lif knownl <br />,,>�, <br />FuhM1c Works P� r <br />�inn oent. • ��1.� � — <br />� <br />D1 <br />City Zip <br />Attach tow (4) copies of plans lor proposed work � Draw to scale and note the following as applicable: <br />• F�roperty Lines <br />• Jutlme and dimensions of all existing and <br />proposed otructures on the lot <br />• Eaisting and proposed utilities <br />Publ¢ Wo�Fs Fec 5 <br />iotN Fee <br />Less Appl. Fee Paid $ <br />Oalanr,e Duc a <br />• Centerline of street <br />• Indicate North <br />• Show any proposed graAing changes <br />• Show measurements <br />P�is-�la� <br />PERMIT CONUITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259•$810. <br />2. All work shall be pertormed 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-SOO•424-5555. <br />Approved lor Construction <br />FINAL INSPECTION <br />Approve'. as Consiructed <br />evere.. PUdLIC WORKS DEPARTMENT <br />� 3200 Cetlar Sireel <br />Everett, WA 99201 <br />Phone: 259•�670 <br />�� �/��r' �� <br />/ <br />Date <br />Date <br />�. � <br />'�c.'l _-fs�<i /Y <br />J� j �',7' � <br />ACKNOWLEDGEM[NT OF CONDITIONS <br />W <br />H <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The undorsigned owner/applicant hereby agreas �o hold and save harm� <br />less the City ol Everett irom 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 from ihe <br />Cily and to replace public property damaged �hereby. <br />Si9nature of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTCD 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 BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />