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oate��3 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Qwner <br />Describe Proposed Work <br />Prolecf Address (if known) <br />Mai{ing <br />Mailing Address <br />Publk Worlu Permit • _/ � � <br />B�Ep. Dao�. � � <br />i�i��iv <br />Vublic WorW Fee <br />TOIaI Fea s <br />Less AppL fea Paltl S <br />B�Ience Due i <br />Zip Phone <br />Attach four (4) copies o( plans for proposeA work - Draw to scale and note ihe following as applicable: <br />� Property Lines • Centerline ol street <br />• Outline and dimensions of all existing and • Indicat� North <br />proposed structures on ihe lot � Show any proposed grading chanyes <br />• Existing and proposed utilities • Show maasuremenis <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be mede 24 hrs. in advance - phone 259�8810. <br />2. All work shall be pedormed in accordance with tbis permit and current Clty of Everett Design and Construction <br />Standards and Specifications <br />3. Call Location Underground Service 4B hrs. befoie you dig. TOLL FREE NUMBER 1-8i)0�4245555. <br />1. A 55 gallon drum full of abeorbant material shall be kept in a <br />locab�on convenient to the fueling island and tanker trenefer <br />areas. The abaorbant material shail be used in the clean-up of <br />any spills of easoline or oil. In addition, an emptY 55 gallon <br />drum ahall also be kept on the aite for diaposal of vaed <br />abaorbant. <br />2. Inetructi�ns on responding to an accidental epil� ahall be made <br />availiable to all employeee and ahall be Posted in vieible <br />locationa. <br />3. Signe muet be poated noting the location of the pump ehut-off <br />aWitch(ea). <br />W <br />H <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />4. Concrete-filled ateel pipe posts (eee City Standard No. 510) �� <br />ahall be conatructed and locat9d where neceeearY to P�vent <br />vehiclea entering the fuelinE �a f� Striking the punpe. <br />`• As ��✓ <br />XL�/bVe� �%�y d��.:G� ,(/u/si� ACKNOWLEDGEMENT OF CONDITIONS <br />_�� 7 <br />� /� <br />FINAL INSPECTION <br />Approved as Constructed <br />��PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everetl, WA 98207 <br />Phone: 259-8810 <br />ZZ- <br />The undersigned ownerlapplicant hereby agrees to hold and save harm- <br />less ihe City of Everelt irom eny and all claims for damagec, cosls, <br />ezpenses, or causes of action that may arise because of installation <br />3 and maintenance of the improvement or other right•of•way use hereto <br />— applie r an further agrees to remove same upon notice irom the <br />City d o r ace public property damaged thereby. <br />- YIz �3 <br />Signalure o A lic nt Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />1B0 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 OURATION. <br />