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Date_ <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Public Works POIWA•-/�y/y�-��^�/�T` <br />Bldg DePI. •/ / "�/v <br />Public works Fee • Total Fee -- <br />Let trot Fee Paid t{ <br />Balance Due • <br />Ap cant Mailing Address City Zip Prone <br />Describe Proposed Work r- �f—/4 <br />LU <br />Prolect 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 />♦/� <br />• Outline and dimensions of all existing and • Indicate North <br />v♦ <br />proposed Prruclures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />�p <br />DO NOT WRITE BELOW THIS LINE <br />PERMIT COIJDITIONS <br />O <br />1. All calla for inspection shall be in tote 24 hra In advance • phone 259.881 5. <br />2. All work shall be performed In accordance : ,ith this permit and current City of Everett Design and Construction <br />Standards and Speciflcatlnna <br />3. Call Location Undergroun.' Service 48 hrebefore you dig. TOLL FREE NUMBER 1-800.424.5555. <br />z <br />�3Gr.I�ol <?o c - 8 z <br />Approved for Callistruction Dale <br />111ii? <br />FINAL INSPECTION Date <br />Approved as Constructed <br />t•vrmit PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett, WA 98201 <br />820161 <br />Phone: 259.8815 <br />r•11 <br />�J <br />10/06/86 2o42PM 00DA02293 attyy <br />#00017072 <br />BLDG $369.00 v <br />PLBD $45.00 ^ <br />MECH $26.50 <br />B BRM $1.50 <br />E SRCfI $�',1+�5�T.��0m100 <br />ACKNOWLED F MOONS <br />The undersigned owner/applic �y eq[Qps, hold and save harm• <br />less the CI'V of Everett from I rT or damages, costs, <br />expenses, or causes of actin arlse because of installation <br />and maintenance of the ImproveOM or other right-of-way use hereto <br />applied lot and further agree>Et"WRove sgpg90Ton notice from the <br />City and to replace public protMed thereby. <br />J �SE .0 <br />U49191.00 <br />Signature of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DA'. E 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 />