Laserfiche WebLink
�. <br />Date f f/ 7/�(� <br />/ Applica�ion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Sir� ti r c f rri �/1 �� %C� i, %/�ilJ �dP� <br />a}'%F 9 <br />�p� Ma ling Address <br />Mailing <br />Descri6e Proposed Work <br />Project Address (if known) <br />City <br />City <br />. ..,b.._._ <br />PubLc WorMs Pormlt • . <br />8109. Dx01. � ��/� �� _� . <br />Public WorNs Foo $ <br />To�al Fvo <br />Less FpP� Foo PniE S <br />Balanco Duo $ _ <br />Zip <br />Zip Phone <br />Atlach four (4) copies of plans lor proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centedine ol street <br />• Ou�line and dimensions ol all exis�ing and • Indicate Nor�h <br />proposed slructures on the lot • Show any proposed grading changes <br />• Ezistina and proposed utilities • Rhow measuremenls <br />PERMIT CONDITIONS <br />1. All calls for inspeclion shall be made 24 hrs. in advance - �hone 259•$81 5. <br />2. All work shall be performed in acwrdance wilh ihis permil and current Ciry of Eveietl Deeign and �onstruclion <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424-5555. <br />. <br />Pl/.c�L,� G�o,r�:�- s�r--�- ��.T,r,or,E:���a,.E�-s - �,(i � ,�8� <br />ST.c�rT �/JJ� �o�/.=m<-=a%S li+.'-i.oCCrC /Jl ,� � <br />Approved lor'Construction Date <br />FINAL INSPECTION Date <br />Aoproved as Construcled <br />evere�t PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Evere�t, WA 98201 <br />Phone:259-8875 <br />� <br />O <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less Ihe Ciry oi Everett I�om any and all claims lor damages, costs, <br />expenses, or causes ol action that may arise because ol installation <br />and mainlenance of Ihe improvement or other right-of-way use hereto <br />applied lor and fur�her agrees to remove same upon notice Irom Ihe <br />Ciry and lo replace public properry damaged thereby. <br />Signature ol Applicant Dale <br />WOFK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGEI�TLY PURSUED TO COMPLETION. THIS PEFMIT MAY 8E <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />