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Date 11.11.13 b �! <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />d U'C_tjAt,✓ <br />ng <br />Describe Proposed Work <br />Address <br />City <br />Public wmk. n.'m <br />�7 <br />aide Oe01 <br />Nbbc Work.Fee $ <br />Toll Tee <br />Lea. ebei fee eud <br />a.hnce N. <br />%S3 3;2- <br />-)e <br />Zip Phone <br />Protect Address (11 known) <br />Attach four (4) copies of plans for proposed work - Draw to scale and note te floing nterline a apeeitcable <br />Ce <br />• Properly 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 shall be made 24 hisin advance - phone 259-81315. <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 hra. before you dig. TOLL FREE NUMBER 1.800.424.555 . <br />J <br />Z <br />Approved for Construction to <br />i5r) <br />FINAL INSPECTION Date <br />Approve 1 as Construr-.ted <br />E6evemtt PUBLIC WORKS DEPARTMENT <br />3200 Cedar Street <br />Everett. WA 98201 <br />T Phone. 259.8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigns- 'wrier/applicant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages. cost% <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the improvement or other rightof-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace p Ilc pro ty damaged thereby. <br />Ilcant Date <br />Sigltatwe of pp <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. 0 <br />