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• <br />Date <br />4 <br />Application For m <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />O <br />0 <br />q pp O <br />1 <br />co od osi <br />1<« M f 1i t 70 / 1 Ii. £ , SEATTLE= %7 Co 3- E)31 <br />Owner Mailing Addresco " City Zip Phone <br />gF-w <br />Applicant Mailing Address <br />Public Works Permit a <br />Bldg. Dept 1 <br />o <br />T <br />Put Works fee $ oe dr <br />Total Fee c! , <br />Less Appl. Fee Paid $ <br />Balance Due $ <br />Describe Proposed Work (2-1 PA" y'KI C k/e.4Eil4(, <br />City Zip <br />Phone <br />17 :di <3T. Afterfrice <br />Project Address (if known) <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines <br />• Outline and dimensions of all existing and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />• Centerline of street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measurements <br />DO NOT WRITE BELOW THIS LINE <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259-8810. <br />2. All work shall be performed 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 1-800-424-5555. <br />c 449y- i vt CA -t-> CI KC d r K CO (/ <br />12.4-y- 7-3 <br />,-,,,k7/0./1--c/a 41 /4--oe <br />A prove for Construsjto <br />Approved as Constructed <br />everett <br />\e <br />PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259-8810 <br />W <br />N <br />'m <br />0 <br />z <br />0 <br />F <br />N <br />0 <br />.a <br />ACKNOWLEDGEMENT OF CONDITION; <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from 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 the <br />City and to replace public property damaged thereby. <br />7/4 -if <br />Signature of Applicant • Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED 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 />