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6v ' <br />Date�� <br />Application For <br />PUE3LIC WORKS PERMIT <br />Pu�li<YloiksPermil+ �__{_yiG ' - ' <br />Blaa. oeo�. � _1J.Q � <br />Pu�l¢ vloMs Fee <br />iotalPee g — <br />� Less Appl. Fee PaiO 5� <br />Balance0un $ �O—_ <br />Print or Type Only <br />y - �lsf D�n �!! <br />ng <br />f� <br />Phone <br />� Applicant Mailing Address Ci�y Zip Phone <br />Describe Proposed Work �rdL <br />Project Addrets (if known� ��VS — <br />httach four (4) cepies of plans for proposed work - Draw to scale and note the following as applicahle: <br />• Property Lines <br />• Outline and dimensions ot all existing and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />Approvedfor <br />• Centerline ol sireet <br />• Indicate Nor�h <br />• Sho.r any proposed �rading changes <br />• Show measurements <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 ihis permit and current City ol 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 />FINAL INSPECTION <br />Approved as Constructed <br />everett PUBUC WORKS DEPARTMENT <br />� 3200 Cetlar Street <br />Fverett. WA 90201 <br />�hone:259-8810 <br />Dale <br />ACKNOWL'cDGEMENT OF CONDITIONS <br />�/3 <br />�w <br />� / <br />O <br />a <br />The undersigned owner/applicaN hereby agrees to hold and save harm- <br />less the City of Everett trom any and all claims lor damages, cosis, <br />expenses. or causes of action that may arise because ol installation <br />and maintenance ot the improverneM or o�her right-ot-way use hereto <br />app�ied for and lurther agrees lo remove same upon no�ice Irom ihe <br />City and lo replace public property damaged ihereby. <br />�-i9 � <br />Si,�nature of Appli ant C Date <br />WORK AUTHC IZED BY HIS PERMIT MUST BE STAFiTED 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 0Y T!iE CITY UPON ANY STOPPAGE OF WOFK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />