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� <br />Date � <br />Application For <br />PUBLIC WORKS PERM:T <br />Print or Type Only <br />� <br />Pu01ic Works Pormoi� r �_� <br />Bltlg. Deoi. � r' � �. <br />Public Wurlcs Fea <br />TotalPoe $ <br />Less ApPI. Fee Pair1 � � <br />i <br />Balnncc Oue $ �O — <br />ne <br />_ ��=1ii�ll� <br />Applicant Mailing Address City Zip Phune <br />Describe Proposed Work ���� i r��-1C� <br />Project Address (if known) -�3�`� - S� �� S� � S, br/. LoT9 0� .'r« "`/ <br />Attach four (C) copies of plans for proposed work - Draw to scale and note the following as apnlicable: <br />• Property Lines • Centerline of stro<� <br />• Outline and dimensions ot all existing end • Indicate North <br />proposed structures onthelot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />P� RMIT CONDITIJK � <br />1. All calls for inspection shal: be made 24 hrs. in advance - phone 259•881 5. <br />2. NII work shall be pc�formed in accordance with this permit and curr. nt City�uf Everett Design and Construction <br />Standards and Sper,ifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREt NUMBER 1-800-424-5555. <br />� 1�u.ST�I[ L v�'�G'EcJA1/ fv.�.5' Cvr /�Ez C/Ty s>A�✓_n,qe� <br />�`�07 9.a'o �S'rLT�c/✓ '3_ 3.7 <br />.S: _i` �'O�f = T'!� .O,C�F�/�i l•q�;-r /.f i;�Un/ O�li' TU SiOECr/>I'l,� <br />TNS7X�LG �PESi1JC/./TiAG Sr.��!il�'� _');'�.n/ ,1?'� ('/?f/ <br />SYA,ciDA�D ''� 3� 9 . �9�rAc<iE�, <br />��� <br />` / / /o �� i 7 <br />FII� SPECTION Date <br />Approved as Conslructed <br />evere[t PUBLIC WORKS DEPARTMENT <br />U3200 Cedar Street <br />Everetl, WA 98201 <br />Phone:259�8875 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />✓ <br />� <br />O <br />� <br />� <br />O <br />a <br />The undersigned u+✓r:er/applicant Iiere�V agrees to hold and save harm- <br />less the City of Everutt from any a�.i :�I claims for damages, costs, <br />expenses, or causes of action that may arise bscause of installation <br />and maintenance of the improveme:,i or ..ther right-of-way use hereto <br />applied for znd further agrees to remove same upon notice from the <br />City and,to replace public property c,amaged thereby. <br />� / i <br />�� % �' � �c�. .f � �� ��, <br />Si9nature of plicai�t � / Date <br />WORK AU � RIZED BY THIS PE:RbF MUST BE STARTED WITHIN <br />190 DAYS F DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PUASUED TO COMPLETION. THIS PERMIT MAY BG <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON TFIIS <br />PROJECT OVER 90 DAYS DURATION. <br />