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Dated <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Mailing <br />rwolK Works rermil • 86 __/J2C-7 <br />Bldg Derl . � o <br />rubl¢ works Fee <br />Told Fee <br />Let, eppl, Fee Fero S <br />Bumce 0.0 S ZO ao <br />F4 <br />Zip Phone <br />Describe Proposed Work' — <br />r <br />W <br />Project Address (if knovfn) — <br />y <br />I <br />for Draw to scale and note the following as apiflicable: <br />Ittttttt� <br />Attach four (4) copies of plans proposed work • <br />• Property Lines • Centerline of street 1 ✓ ^ <br />• Indicate North /)\ <br />♦^ <br />v♦ <br />• Outline and dimensions of all existing and (I <br />proposed structures on the lot • Show any proposed gradingtcll <br />• Existing and proposed utilities • Show measurements <br />WO <br />DO NOT WRITE BELOW THIS LINE <br />PERMIT CONDITIONS <br />1. All Calls for inspection shall be made 24 hrs. in advance • phone 259.881 5. <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 />%�% SFtiioiF DF u'.elk'a-i✓ey/ /,f/ TiYE <br />Sf!^tt /aE cW Cewc eEr� <br />LvYTy te Scct-E— er" A?,ki u, a';;', Atdi+1/ Irc�c"+ Tio� <br />�r pf C�i'i'FK �ivC+E �PQ9v iu TyE f�bvFP�j/ L/NE, <br />S !%E'i�Fr.✓/��/ rn�rrrb'f f%T GE�OJT Pc fEET F��� <br />V.✓c Ec✓,.iy D.0 /,�/Y."rC%f /�i,G'.oEr-'T� <br />/O <br />lip <br />u <br />Approved for Constr ction le Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />Ever Cedar Street <br />Everett, WA 98201 <br />Phone: 259.8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned oliner/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 actiO644YWY pty�RlLm(10pg0K8?Ieu3 Ci <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agree same upon notice from the <br />City and to replace public pro � f thergby. <br />90. <br />ignature of Applicant CHECK $111.50 / Date <br />WORK AUTHORIZED BY THIS PERMIT Mt1ST BE STAPTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEPEAFTER 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 />