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.T <br />DateiLld? <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />7i3 S.f.. f-�e,X"!rn It" "'1/ aapy <br />r,'5 EdcQ.7)' cvaS� <br />Mailing Address City i <br />Melling Address <br />City <br />i <br />Describe Proposed Work COrt/ S �'P. s�'_.�..— ' TF R M ' �G S' <br />Project Address fif known) <br />Pubuc Work. Permit . <br />Bldg Deer <br />Public Works Fee f{ <br />Tolal Fee <br />I. e.s APPI Fe. Paid S --- <br />Balance Due <br />�G9�9 <br />Phone <br />Phone <br />Attach four (4) copies of plena for proposed work - Draw to scale and note the following us applicable: <br />• Property L ines • Centerline of street <br />• Outline and dimensions of all c Oiling and • Indicate North <br />proposed structures on the it • Show any proposed grading changes <br />• Existing and proposed cell•. r^ • Show measurements <br />.•dWAIW <br />PERMIT CONDITIO C3 <br />1. All calls for Inspection shall be made 24 lira. In advance - phone 259.881 5. <br />2. All work shall be performed in accordance with this eermit and current City of Everett Design and Conslnletlon <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before ynu dig. TOLL FREE NUMBER 1.800.424.5555. <br />Approved for on uctlon Dete <br />lv/alas <br />FINAL INSPECTICIN Date <br />Approved As Construc'ed <br />W <br />PUBLIC WORKS DEPARTMENT <br />3200 Ceder Street <br />Everett, WA E8201 <br />Phone: 259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />z <br />A <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 nr other right-of-way use hereto <br />applied for and further agrees to remove same upon notice from the <br />City and to replace public property damaged thereby. <br />S nature of Applica Date <br />WORK AUTHORIZE 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 />r~ 2 <br />� N <br />� 'll <br />gn 20 <br />m <br />rn <br />N <br />�r <br />c N <br />vl <br />zr <br />. m <br />A <br />1 <br />S <br />a <br />z <br />-.1 <br />x <br />