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Date� � <br />Application For <br />f�UBLIC WORKS PERMIT <br />Print or Type Only <br />�1 ^ �. <br />Describe Proposed Work �!�� � � �'� <br />Project Address (if known) <br />Address <br />- J � �`' S�- <br />Lip <br />PUCIic Works Permil x � �" <br />G <br />91tlg. Depl. + _=L <br />PublicWorksFee S <br />Total Fee <br />Less Appl Fee Paitl $ � <br />eaiance Due $ � <br />oT <br />Attach four (4) copies of plans for proposed work • Draw to scaie and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and A Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measuremenis <br />PERMIT CONDITIONS <br />rnone <br />Phone <br />G�l "` <br />i. All calls fcr inspection shall be made 24 hrs in advance - phone 259•881 5. <br />2. All work shall be performed in accordance with this perm•t and current City o( Everett Design ann .;onstruction <br />Standards and Specificatiuns. <br />3. Call Location Underground Service 48 hrs. betore you Cfg. TOLL FREE NUMBER 1-800-424-5555. <br />y ��,�-E«JA� T� .�E_ �,�5;,��cC� :��,�� c;�y o� .����,��Tr- <br />S':fl.voiS'�v .�1 3_3.7 .9��0 ,��� ��r,�ic �` 3��7 <br />// i ,� � <br />i /� n .�f2� G�G� �� - <br />Apprnved tor ConStr -- Date <br />/G-1i-f 7 <br />FINAI_ P CTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Sireet <br />Everett, WA 98201 <br />Phone: 259•8815 <br />ACKNOWLEDGEMENT UF CONDITIONS <br />W <br />� <br />� <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett (rom 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 �he <br />City and to replace public property damac�ed thereby. <br />�/ �� <br />�.i l'[C n �'C'r�'�— `�/ 5'/5'7 <br />Signature of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERM!T IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY P�, <br />CANCELLED BY THE CITY UPON ANY STOPPAV� OF WORK ON T� � <br />PROJECT OVER 9Q �AYS DURATION. <br />