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Date �'" z z' SC1 <br />AppLca�ion f�r <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Applicant <br />37� Q 2,.� Na <br />Mailing Address <br />Mailing Address <br />Ci�y Zip <br />PuOi¢ Woiks Per a <br />BIOg. Oept • <br />PuplicWork ee <br />T^•al Fe � <br />Less AOPL Fee Paia 5 _ <br />Balance Oue $ <br />��2a/ 2s9-3f36 <br />Phone <br />Describe Proposed Work uU ✓if i�S / � � ��� !C Q � � �V �_ �� ���R �= J <br />Project Address lil known) <br />Attach four (4) copies of plans br proposed work - Draw to scale and note ihe following as applicable: <br />• Property Lines <br />• Outline and dimensions of all existing and <br />proposed struclures nn the lot <br />• Ezisting and proposed utilities <br />• Centerline ot sireel <br />• Indicate North <br />• Sho�v any proposed grading changes <br />• Show measurements <br />PERMIT COM1DITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shall be pedormed in accordance with ihis permit and current City ot Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hr,. before yuu dig. TOLL FREE NUMBER 1-800•424•5555. <br />""1 . �E."�l.k.:CTf�/� �:������ ��CG.V�ILLiJ <br />C7C.'Y� U V tJ � f 1,,." �-�,O '`� <br />�`�C¢s�Q- V��`l�'— � Zz " �U <br />Approved for Construction Date <br />FINAL INSPECTION Date <br />Approved as Consiructed <br />everett PUBLICWORKSUEPARTMENT <br />� 3200 Cedar Street <br />Everett. WA 98201 <br />Phone:259�Ad10 <br />ACKNOWLFDGEMENT OF CbP:DITIOPIS <br />W <br />H <br />_ / <br />� <br />0 <br />The undersigned owner/applir_ant hereby agrees to hold and save harm- <br />less ihe Ci�y ol Everetl trom any and all claims for damages. costs. <br />expenses, or causes of action that may arise because of installation <br />and r.iaintanance of the improvement or othe� right-of-way use hereto <br />appii�d tor and lurther agrees to remove same upon notice trom the <br />City end �o rep:ace public property damaged thereby. <br />l� �ir, �a,l'i�r, �-� 2 -90 <br />Sipnature ol Applicant Oate <br />11'OP.K AUTHORIZED BY THIS PEFMIT MIIST 8E STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTEF IS TO <br />BE DILIGENTLY PURSUED TO COMPL[TION. THIS PE:RMIT MAV BG <br />CANCELLED BY THE CI'�Y UPON ANY STOPPAGE O� WORK ON THIS <br />PROJECT U`/Efl 90 DAYS DURATION. <br />—i <br />