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Uate <>/!�5/_d"� <br />/ � � <br />Application For <br />PUBLI� WOR165 PERMIT <br />Print or Type Only <br />3o i � -( �,7ti <br />Mailing Address <br />ailing Address <br />Pu�hc Works Permit + >! <br />BIag.DeO�-+ /�(/� <br />rubhc worFs Fcc <br />TOial Fee � <br />Less Aopl. Fee PaiJ S <br />D,ianco o�c 5 <br />asa- <br />City Zip Phone <br />Describe Proposed Work _ 1/ P C I� � r S, �7p /p � i,{q ����p <br />T <br />Proler,t Address (if knuwn) <br />— / !_ 7-!t <br />Atlach four (4) copies of plans for proposad work - Draw to scale and note ihe following as applicable: <br />• Properry Lines <br />• Ouiline and dimensions of sll existing and <br />proposetl siructures on iha lot <br />• Existing and propose,�, utilitie5 <br />O Centerline of st�eel <br />! Indicate North <br />• Show any proposed yrading changos <br />� Show measuremenis <br />WRITF BELOW TH <br />PERMIT CCNDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shall be par�ormed in accordance with this permi; and current City of Everett Design and Construction <br />Standards and Spe.;�cications. <br />3. Call Lecation Unaerground Service 48 hrs. hn�ore you dig. TOLL FREE NUMBER 1-800•424-5555. <br />i l/6GiG Gva2,�.°s i�,�,L�iri.i �T' ,e�� <br />� <br />Approved for Consiruction Date <br />FINAL INSPECTION Date <br />Approved as Consiructed <br />evrrett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everet6 WA 98201 <br />Phona 259�8970 <br />ACKtJ�JIVLGDGCA7ENT Of CONDITIONS <br />T. he unUersigned ownodapplir.;m� hereUy agrees to hold and 5ave harnr <br />less fhc City of Everett Irom any and all claims for dama9es, costs. <br />expenses. or causes of action that may arise because of installation <br />and mainfe�ance of the improvement or olher right�of�way use hereto <br />applied for and further aqrees �o remove same unon noti�e from ihe <br />City and to replace public property damaged ih�rel;q <br />Signature of Applicant � ���� <br />WORK AUTHORIZ[D BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER I� TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLEU BY THc' CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />I y� <br />I . �. d <br />