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M <br />Date6-13 -51 Public Works Permit s <br />Application For Bldg Dept.. <br />PUBLIC WORKS PERMIT Public Works Fee <br />Total Fee $ — <br />Less APPr Fee Paid $ q _ <br />LQ <br />Print or Type Only Balance Due $— <br />n- rl +ifl fie SC LVeF-e-h gF5�-D K 3s5--g503 <br />Mailing Address City Zip Phone <br />Applicant Mailing Address City Zip Phone <br />Describe Proposed Work CUQ/3 BEN/ N> r-A! L- (AT- %aP OF IVALL.) TD <br />e EV�ILAV0 - FALLING l N7D yA�D <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 />• Centerline of street <br />• Outline and dimensions of all existing and <br />• Indicate North <br />proposed structures on the lot <br />• Show any proposed grading changes <br />• Existing and proposed utilities <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259-8810. i �l4g11 1 n ngC�H COOfi1kb487 <br />2. All work shall be performed in accordance with this permit and current City of Everett DesWJI t,'ensttuchon' <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800 43M. <br />DFuw.r '20.00 <br />CHECK $20.00 <br />e ec4 <br />by JAJ W;11;an5 <br />-V'� G'ee-- 5-- E4- 9 / <br />Approved for Construction Date <br />FIN L� IN-9PECTI'ON Date <br />Approved as Constructed <br />PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />Phone: 259.8810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />z <br />O <br />v♦ <br />O <br />a <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 />`knAIhhN G�Lth��Rt.0 5'-lS--q 1 <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 />