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kI <br />Date ii S-3 <br />Application F,r <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Owner <br />Mailing <br />f 1 <br />Describe Proposed Work S F /i <br />Project Address (if known) T <br />Public Work. Permit e 2 <br />elep Dept • __ <br />Public Worke Fee s� Q O V <br />Tpt.l fee <br />Lae. Appt Fee Paid 8 <br />Beience Due 8 LL 0 . Q sz - — <br />WE <br />Attach lour (4) copies of plans for pioposod work - Drew to scale and note the following as applicable: <br />• Property Lines • Conterline of street <br />• Outline and dimensions of all existing and • Indicate North <br />pioposod structures on the lot • Show any proposed grading changes <br />• Existing and proposed utilities • Shcw measurements <br />PERMIT CONDITIONS <br />1. All calls for Inspection shall be made 24 hrs. in advance - phone 259.881 5. <br />2. All work sha'I be performed In accordance with this permit and current City of Everett Design rind Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 481 before you dig. TOLL FREE NUMBER 1.800.424-5555. <br />8y <br />W <br />IM <br />M <br />O <br />z <br />0 <br />N <br />O <br />a. <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 righl-of-way use hereto <br />_ L applied for and further agrees to remove same upon notice from the <br />A¢(roved for Construction j / Date City and to replace public property damaged thereby. <br />>0 <br />FI L I PECTION Date Chile <br />Mg <br />Approved as Constructed Signature of Applicant <br />WORK AUTHORIZED BY THIS PERMI UST BE STARTED WITHIN <br />Pverett PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />3200 Ceder Street BE DILIGENTLY PURSUED TO COMPLETION. THiS PERMIT MAY BE <br />Everett, WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK 014 THIS <br />Phone: 259.8815 PROJECT OVER 90 DAYS DURATION. <br />i <br />I <br />_J <br />