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Date�3 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Pyplic Work, Plrmn• <br />Bldg DepL, <br />u <br />PuGk, o Welke Fee T` 'ob ke <br />oe <br />Lew Appr Fee Pnd ` O�Q� <br />0.1me Due <br />6Z4.20 <br />rii9A/� 'RI �T �7dJGs�scDL•lf-rC/�3r,3-4 <br />�Phone <br />rnv Zlp Phone <br />/ i <br />Describe Proposed Work .f !fn <br />�1,<-0 �-- <br />Project Address (if known) <br />Attach lour (4) copies of plans for proposed work • Draw to scale and note (,enitefllne of alPeelt able: <br />• Property Lines • Indicate North <br />• Outline and dimensions of all existing and • Show any proposed grading changes <br />proposed structures on the lot • Show measurements <br />• Existing and proposed utilities <br />PERMIT CONDITIONS <br />1. All calls for inspection shell be made 24 hr& 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 Specification& <br />3. Call Location Undergrcind Service 48 hr& bulore you dig. TOLL FREE NUMBER 1-800.424.555 . <br />-isc.D - .ASG a x,.�Lha Ar.Ntwo1 r k ...w <br />�lf.Jewa ,a ft�".f.J! `NG 2r-L, ��•e �f.uG wn MK,t' bfC re N,ou� <br />ec� <br />43 <br />Date <br />.R provod for Construction <br />i--�✓y':f, <br />FRML INSPECTION Date <br />Approved as Constructed <br />everott PUBLIC WORKS DEPARTMENT <br />Ever Ceder Street <br />Everett, WA 98201 <br />Phone: 259-8815 <br />M <br />O <br />z <br />O <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The nt hereby agrees to <br />d and soya harm, <br />undersigned <br />leas the City of Everett from laany and all t <br />claims fordamages. cos a <br />expenses, or causes of action that may arise because of Installation <br />and maintenance of the Improvement of other rlghton notiwayce <br />use hereto <br />mend further agrees to remove same upon notice from Ina <br />v end to reolace public property damaged thereby. <br />Data <br />31 eture K AUof ADID <br />180ROAYSTOF DATE PERMIT ISESSUEDUSD THEREAFTER ISARTED HTO <br />BE DILIGENTLY PURSUED TO COMP ION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON AN ON <br />OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATI <br />