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DateG� S <br />Aopllcation For <br />Pl1�LEC WORK� P�R�191T <br />Print or Type Only <br />Publlc �Naiks Permlt • ��/��`�' <br />Bldg. 0ept. x�� ,% � Y. �_ <br />Fublic Works Fee <br />Tofal Feo S — <br />I.cr Appl. Feo Peitl S . <br />a�i,�oao�e S GO,Or� <br />�cu;�-K _ f./,<<�5 ,�o,„�s Sati sv' cv��Gn ��.� �v�/ L"✓c�ze?r ,�iv� 3sr-��y,z <br />Owner Mailing Address City Zip Pi,one <br />� wntc� <br />Applicant <br />Mailing Address <br />DescribeProposedVlork �NSi�KL o�S�uJ/� (p1X/1GIE /�/1/�/r_2U�¢� <br />Proiect Address (il kno�vn) �r � � �E'�t�'�E ����5 � TSn� -- 7�-�� l�it' � <br />Attach fovr (4) copies o' plans for proposed work - Draw to scale and rote the following as applicable: <br />• Property Lines <br />• Outline and dimensions of all existing and <br />proposed structures on the lol <br />• Existing and proposed utilities <br />PGRMIT CONDITIONS <br />• Centerline ot street <br />• Indicate North <br />• Show 2ny proposed grading changes <br />• Show measurements <br />Phone <br />1. AII calls for inspection shall be made 24 hrs. in advance - phone 259-881 5. <br />2. All work shall be performed in 2ceordance witti Ihis permit and current City ol Everett Design and Construction <br />Stand2rd� ar.0 Specifications. <br />3. Call Locatit,i Undeiground Ser,�.7r,� 4f3 hrs. befoi2 you diy. TOLL FREE NUMBER �-SOO-4Z4-SrJrJS. <br />Approved Icr Construct%n � ��e <br />� i� �� <br />FIIIAL ,NSPECTION Date <br />AGI���o`ied as Constructed <br />evem[t PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phona 259-8815 <br />AC'<NUWLC-DGEMENT OF GONDITIO`JS <br />Th�� undec.��7ned owner/applicant hereby agrees to hold and save harm� <br />less the City ol E�erett irom any and all ciaims for damages, costs, '� <br />exUenses, or causes o( action that may arise because o( installation I <br />and maintenance of Ihe improvement or other rigM-of-way use hereto '. <br />applied for and Wriher agrees to remove same upon notice Irom ihe <br />City and to replace py0lic property damaged thereby. <br />S' ot Applicy�fit Da�e <br />N' K AUTHORI7.ED BY THIS PEF..11T MUST BE STARTED WITHIN <br />0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS i0 <br />BE DILIvENTIY PURSUED TO CO�v1PLETION. THIS FERh11T MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAG[ OF WORK ON Tfi1S <br />Pf70JECT OVER 90 D�YS DURATION. <br />