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Date !/ <br />Application For <br />PUBLIC WORKS PEPMIT <br />Print or Type Only <br />Pubs¢ Wake Per Qq/C� yQ/�, <br />Pfiled Depl.. �]T j--.. <br />Pubkc Works Fes S <br />Total Fee — <br />Les AN, Fee Pbd S <br />seems Due S <br />Applicant Mailing Address City Zip Phone <br />Describe Proposed Work��� <br />Project Address (if known) <br />Attach four (4) copies of plans for proposed work • Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <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 this permit and current City of Everett 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 />/f'olea�se,i <br />/y" Az wee" �cA J� <br />Approved for Co ruc,Wn Date—g <br />FINAL INSPECTION Dale <br />Approved as Constructed <br />PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />everett <br />Everett. WA 98201 <br />8201 <br />Phone: 259.8810 <br />Cl/ <br />M <br />W <br />0 <br />0 <br />#00027216 1 I.L <br />SEWER $30.00 L <br />BND I $600.00 <br />DAM* 166MAA00OOA46360 � <br />ACKNOWLEDQRM9T VSMU JIONS <br />The undersigned owner/appll#@0U2LrM agrees to hold and save harm- <br />less the City of Evereif frorrr���ggqssssss and �i for damages, costs, <br />expenses. or causes of acts aI may $ £e cause of Installation <br />and maintenance of the imp ent or dt dr hhol•way use hereto <br />applied for and further agre�fEEN removeli"a Pon notice from the <br />City and to replace public prc{pooM mage431) ftby. <br />E SR11 415.00 <br />420 <br />Signature of Applicant Up �p �t,tr,f1— / Dele <br />WORK AUTHORIZED BY HT3TI�EAMIT'M ME STARTED yVIT_H�lN_ <br />180 DAYS OF DATE PERMIT IS ISSUED AND THE REAIZ31N'11 I�klib <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 />