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Date � a Sl <br />Application For <br />PUBLIC WORKS PCRMI�" <br />Print or Ty�e Only <br />Applicant <br />Mailing Address <br />Mailing Aadress <br />z�n <br />Zip <br />� <br />PUCIic Woeks Pcrmit + / <br />�I49. De�t. x _��/ � /� <br />Public Worka Fee <br />Total Feo $ � <br />Less Ap01. Foo Paitl 5 _. <br />BalancoUue S <br />r a i'�- �-Z _; <br />Phone <br />Phone <br />/� H o <br />Describe Proposed Wor!c G�i/� '� �-�u—�'-- _ "i <br />� <br />m <br />Prolect P.ddress (il known) <br />Attach four (4) copies of plans tor proposed work - Draw <br />o Properry Lines <br />� Outline and dimensions of all existing and <br />proposed structures on the lot . <br />• Existing and proposed utilities <br />PERMIT CONDITIONS <br />scale and note the foll'owing as applicable: <br />• Centerline of sireet <br />• Indicats Norih <br />• Show any proposed grading changes <br />• Show measurements <br />1. All calls for inspection shall be made 24 hrs. in advance • phone 259•8&1 5. <br />2. All work shall be performed in acrordance with ihis permi� and current City of Everett Design and Construction <br />Standards and Specitications. <br />3. Call Location Under�round Service 48 hrs. before you dig. TOLL FREE NUMBER 1-E.�0-424•F555. <br />/l�'o P����c �,�,�s /��,���r ,��cr�%�o <br />Approved for Construction Date <br />FINAL INSPECTION <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everetl, WA 98201 <br />Phone: 259�8615 <br />Date <br />c�G,�� �2/8S <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />� <br />N <br />� <br />� <br />M <br />Y I� <br />C� <br />a. <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the Ci�y of Everel� trom any and �11 claims for damflges, costs, <br />expenses, or causes ot adion that may anse because ol installation <br />and main�enance of ihe improvement or other righl-oFway use herelo <br />applied for and fur�her agrees to remove same upon notice from Ihe <br />City and to replace public property damaged thereby. <br />SignaWre ot Applicant Date <br />WORK AUTHORIZED BY THIS PcRM1T MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PEHMIT A1AY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />.. .. <br />� � <br />.. --� <br />N� <br />m <br />co <br />m� <br />O 3 <br />m <br />_ -�-I <br />m <br />.. <br />r� z <br />c <br />a -� <br />r x <br />� � <br />< <br />� <br />O A <br />�a <br />�m <br />rn.. <br />N <br />O <br />o r <br />�m <br />3 �Nif <br />m <br />Z� <br />--I r <br />m <br />a <br />� <br />� <br />x <br />a <br />z <br />� <br />x <br />N <br />L <br />�"� <br />H <br />n <br />m <br />