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Date 3 <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only T/ 'dp-�F <br />G e2 .1 <br />n 44 A2, <br />Pubbe Wprke Permli e r V ._ <br />Bldg Dept. • . <br />Pubk Wprke Fee <br />Tprel Fee ! <br />Lne Arpl Fee Paid ! <br />Behnce ew 4 rx/• dy <br />S A <br />Applicant Mailing Address City Zip Phone <br />Describe Proposed Work <br />// It w <br />Project Address (If known) <br />S <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 ullliNis • Show measurements <br />a]i74i <br />All <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 hia. before you dig. TOLL FREE NUMBER 1-800.424-5555. <br />�°�� <br />3-Il-11'Cy <br />AA�ved too-Construcl on <br />Date <br />C <br />FINAL ed <br />'\ Date <br />a I'` <br />Approved ea Constructed <br />PUBLIC WORKS DEPARTMENT <br />' <br />3200 Ceder Street <br />i <br />Everett. WA 98201 <br />Phone: 259-8815 <br />hi <br />Co <br />O <br />z <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/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 action that may arise because of Installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to rapt ce public property damaged thereby. <br />Si ature of Applicant Date <br />W RK 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 />Iz2z <br />