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Date�f-�-� <br />Application For <br />PUBLIC WQRKS PERMIT <br />Print or'fype Only <br />Mailing <br />PuClic Worke Permit • <br />BIEA.Oeol.r �� /�7 <br />PuElic Wo�ke Fee s <br />To��l Fae <br />LassADP�-FeePaid S <br />B�lance Oue s <br />3S�f-� ."3 �-f.,Z <br />Phone <br />Describe Proposed Work <br />Pro)ect Address (if known) <br />�F,r -sz�'° �s� — <br />Attach four (4) copies of plans for proposed work • Draw to scale and note the following as applicable: <br />� Froperty Lines <br />• Outline and dimensions of all existing and <br />proposed slructures on the lot <br />• Existing and proposed utilities <br />• Cemerline ot street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />PERMIT CONDITIONS hone 259-8815. <br />1. All calls for inspection shall ba made 24 hrs. in advance - p <br />2. All work shall be performed in accordance with this permit and cu.rent City ot Everetl Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424•555 . <br />�� <br />� � <br />�In�1 �� y'/. <br />^V1'/r/r /, / _ �. <br />�01 <br />/�/!� <br />Date <br />Approved lor Con;truction <br />FINAL INSPECTION Date <br />Approved as ConsVucted <br />eV� PUBLIC WOFKS DEPARTRIEN7 <br />3200 Cedar Stree� <br />Everett, WA 9B201 <br />Phon�:259�8875 <br />W <br />H <br />� <br />� <br />� <br />O <br />ACKIJOWLEDGEMENT OF CONDI710NS <br />The untlersigned owner/applicanl hereby agrees to hold and save herm� <br />less the City of Everett Irom any and all claims tor damages, costs, <br />expenses, or causes of action that may arise Uecause of installation <br />and maintenance ot the improvement or other right-ot�way use hereto <br />applied lor and lurther agrees �o remove same upon n�lice irom ihe <br />City and to replace public prOperiy damac�ed thereby. <br />Date <br />Siynature ot Applican� <br />80RDAYSTO DAEE PERAIT ISEISSUED`FNDBTHEREAFTER ISHTO <br />B[ DILIGENTLY PURSUED TO COMPLETICN. THIS PERMIT MAY BE <br />CANCELLED BY THF CITY UPON ANY STOPP.4GE OF VJORI<ON THIS <br />PROJECT OVC-R 50 DAYS DURATION. <br />� <br />� <br />tr7 <br />