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� <br />Date�� fi <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Address <br />Describe Proposed Work <br />Project Address (if known� <br />i'/ <br />Giry <br />� <br />� <br />Attach four (4) coUies of plans lor proposed work - Draw to scale and note the following as applicable: <br />• ProGerty Lines <br />• Outline and dimensions of all existing and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />PERMIT CONDITfONS <br />Pu�hc Wa�es Pormit + <br />amq oeoi.+— <br />Pu�LtWarksFee s <br />Total Fee <br />lCss FpPL Fee P8�0 $ <br />6alance Due S <br />• Centerline ol streel <br />• In�icate Norih <br />• Show any pro�osed grading changes <br />• Show measurements <br />Phone <br />Phone <br />1. All calis for inspectiOn shall be made 24 hrs. in advance - phone 259•$$� $. <br />2. All work shall be performed in acCordence with ihis permit and current City of Everett Design and Consiruction <br />Standards end Specilica�ions. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800•424-5555. <br />.G�(� /��� i��`i2����c � �� c u2�-o'/ ' /D� j�6 <br />�� `��� <br />Approved for Conslruclion <br />Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />evere�t PUBIIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Evere��. WA 98201 <br />Phone: 259-8815 <br />ACKNOV✓LEDGEMENT Of CONDITIONS <br />W <br />H <br />� <br />� <br />O <br />�- <br />� <br />O <br />a <br />The unde�signed ownedapplicanl hereby agrees to hold and save harm• <br />less the Cily ol Everetl from any and all claims for damages, cosis, <br />expenses, or causes of action that may arise because ol installation <br />and maintenance ol the improvement or other right-ol-way use hereto <br />applied for and luriher agrees to remove same upon nolice irom �he <br />City anC to �eplace public properry damaged thereby. <br />Signature of Applicant Date <br />WORK AUTHORIZED 8Y THIS PERMIT MUST BE STARTED WITHIN <br />160 DAYS OF DATE PERMIT IS ISSUED AND TIIEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY �E <br />CANCELLED 8Y THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJF.CT OVER 90 DAYS DURATION. <br />