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Date_!!'mot' T <br />Application Fnr <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Address <br />Public Works Permit a 6 7 _ la <br />Bldg Dept. • <br />Public Works Fee <br />Toth Fee f{ <br />Less apor Fee Paid 1{ <br />selsnce Due <br />Applicant Meiling Address City Zip Phone <br />Describe Proposed Work _ Tr1Q/QZD4 % cc],-,, <br />W <br />_ <br />Project Address (if known) <br />Attach lour (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />/A <br />• Outline and dimensions of all existing and • Indicate North <br />v+ <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />DO NOT WRITE BELOW THIS LINE <br />O <br />PERMIT CONDITIONS <br />1. All calls for inspection shell be made 24 hrs. in advance • phone 259.8815. <br />01 <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Cell Location Underground Service 48 hire, before you dig. TOLL FREE NUMBER 1-800-424.5555. <br />z <br />L� <br />y Cu�ztd Gu-TE.e #' S/OEc..1�Jc .� %%c�E /YEv% A.VO G!A/09�i96 f l� <br />IF 1IP2o.rFN sDz1,,1A16- T//i-t li i DUCT D V / y MUST BE <br />&AC,OCEA 8y 7,11E 4&PA,,-AA17- <br />� <br />SCOT 721 BF �r.P40F0 rQ ,9,S /✓07 To 2iWA 7- <br />Ch <br />SCi,e,E'O!,MU,01 dam LdTS- tzh,7r1 f i9in/Cu�OTEC' Pu�/Ofi�, <br />� <br />TE <br />.t'ovf —7�f� j%/r[SPOt/Tl /NiU �' <br />/� <br />0 <br />X01 ? <br />Approved Approved f�ruu Ion ate <br />FINAL INSPECTION Dale <br />Approved as Constructed <br />evereft PUBLIC WORKS DEPARTMENT <br />Ever Ceder Street <br />Everett, WA 98201 <br />Phone: 259;SCi ?YIXJ <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages, costs, <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the Improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace public property damaged thereby. <br />Signature of Applicant ate <br />WORK AUTHG,RIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF , ATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />