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Date <br />Application For <br />PUBLIC WOi�KS PERMIT <br />Print or Type Only <br />Owner <br />Applicant <br />Describe Proposed Work <br />Plan Check No: <br />Applicat.Date: <br />Job Addre�s: <br />Owner: <br />Tenant: <br />Pr000sed Use: <br />Desc. of Work: <br />POLE GAFtAGE <br />B 37491 <br />07/24/92 <br />8909 9TH PL W <br />DUPREE� LYLE <br />GIRAGE <br />SEPA <br />OFFJCE SET JOB SET <br />APPROVED FOR PERMIT: DATE_/_/_ BY <br />Prolecl Address (i( known) _ <br />Attach lour (4) copies of plans for proposed work - Draw lo scale and note the following as applicable: <br />• Property Lines <br />• Outline and dimensions of all exisiing and <br />proposed structures on the lot <br />• Existing and proposed utilities <br />PubLc Wo�ks Pe�mu a - <br />oiaq Deo�� + <br />PuO�¢ Wo�k. Fee S <br />Tota� Fee <br />Less ADoI. Fee Paia S <br />Balancc Due $ <br />s Centerline of street <br />• Indicate Norih <br />• Sh�w any proposed grading cha.iges <br />• Show measuremenis <br />Phone <br />PERP+IIT CONDITION,", <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 255•8810. <br />2. All work shall be pedormed in accordance with �his permit and current City of Everetl Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-800•424•5555. <br />proved �o� Cor+slruction <br />INSPECTION <br />ed as ConsVucled <br />��PUBLIC WOflKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 982U1 <br />Phone�259-5810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />0 <br />� <br />N <br />O <br />a <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the Gty of Everett irom any and all claims tor damages, costs, <br />expenses. or causes of action that may 3rise because of installation <br />and maintenance of the improvement or other righPohway use hereto <br />applied lor and further agrees to remove same upon notice irom the <br />Date Ciry and to replace public properry damaged lhereby. <br />uace Date <br />Signalure of Applicant <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />780 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCFLLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PNOJEC,'' O`.'Er 9') I�R'1S DUFIA��ION <br />