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.O�x <br />H <br />a H rn <br />y 3 <br />C) 0 <br />'U H'i7 <br />r/1 H <br />Hz <br />Oyu <br />�e <br />9HR <br />tr z <br />HH <br />H <br />C) C to <br />X H rn <br />q 0 W <br />Date-41",1 J10) <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />P <br />n.... MallmD Address City Z <br />ApplAicirnf Mailing Address City <br />Describe Proposed Work i r in u a� & 01 ISM 6t <br />Puehc Walrx Par f <br />Bldg DOW e �— <br />Pwbir WOO Fee 8 <br />ioltl Fee <br />Lee, eFPf Fee Pud s — <br />salsece Due <br />Phone <br />Phone <br />Project Address (11 known) —uJ b G — 9?Ad fl <br />1 E - <br />Attach four (4) cepies of plans for proposed work - Draw to scale <br />and note the following as applicable: <br />• Property Linea <br />• Centerline of street <br />• Outline and dimenslons of all existing and <br />• Indicate North <br />proposed structures or. the lot <br />• Show any proposed grading changes <br />• Existing and proposed utilities <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calls for Inspection shall be made 24 hrsin advance - phone 259-8810. <br />2. All work shell be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Locatioil Underground Service 48 his. before you dig. TOLL FREE NUMBER 1.800-424.5555. <br />✓vlJ4'eG� Ie+ar��J.�z.m��/Lc� �e...n...� <br />Approved for Construction Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />0 PUBLIC WORKS DEPARTMENT <br />3200 Ceder Street <br />ff Everett. WA 98201 <br />Phone: 259.8810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />'s <br />Cn <br />W <br />O <br />n <br />z <br />The undersigned owner/applicant hereby agrees to hold and save hi rm- <br />less the City of Everett Irom any and all claims for damages, costs. <br />expenses, of causes of action that may arise because of Installation <br />and maintenance of the Improvement or other right-ol•way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace public properly damaged thereby. <br />Signature of Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE 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 />0 <br />