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Date <br />Application For <br />PUBLIC WORKS PERMI�' <br />P!ini or Type Only <br />�K'l� <br />�i-�I lll .f Y <br />��r� <br />Describe Proposed Work <br />C•J <br />, <br />� <br />� <br />¢ <br />O <br />Q <br />� <br />d <br />� <br />O O <br />p c <br />u+ � <br />! <br />Pu�lic Woiks Permlt s � <br />eiae- oco�� + <br />Pu�lit Warks Fee <br />Tolal Fee $ � <br />Less AOPI. Fee Pmtl g- <br />Balance Due $ ��� _ <br />g� ZC�1Z <br />� v Phone <br />Mailinq Address C�tycn � o� Zip <br />p�� O 3 N <br />s i �� z� q�rh .�hi�• ����L� c� �.4��� o?,o�z — <br />.e.,w.,.. AddfPSS City Zip <br />Pwiect Address lif known) !���� � — <br />Attach four (4) copies ot plans for proposed work - Dra�v to scale and nole � CQ°��erline of streeii able: <br />• Proper�y Lines • �ndicate North <br />• Outline and dimensions of all existing and � Snow any proposed grading changes <br />proposed structures on the lot � Show measurements <br />• Ezisting and proposed utilities <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 thi= permit and current Cily of Everelt De>ign and Construction <br />Standards and Specificalions. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMOER 1•800•424•55 <br />q. P�ti -�-� ���+� �•�. � �,� y�. � f P�-.,.,�- ���:�:� <br />Approved as Constructed <br />PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />EwretL WA 9A201 <br />Phene:259-881U <br />AGf<NOWLEDGEMENT OF CONDITIONS <br />The un�lersigned owner/appiicant hareby agrees to hold and save harm- <br />less the Ciry of Everell 1rom any and all clalms for damages, costs, <br />expenses, or causes of action that may arise because ol installation <br />and maintenance of ihe improvemenl�or other right-ohway use hereto <br />applied for and further agrees lo remove same upon notice trom the <br />City and to replac�,public property damaged ihereby. <br />� jJ <br />----- �;►- Ih-�l� <br />� Date <br />ig ature f plic t <br />WORK AUTHOFlIZED BY THIS PERb11T MUST BE STAPTED WITHIN <br />180 DAYS OF DATE P[RMIT IS ISSUGD AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMFLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PFlOJECI OVER 90 DA'!S DURATION. <br />