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Date Iri-I �''7 <br />Applicalion For <br />�'�JBLIC WORKS PERMIT <br />Print or Type Only <br />Gity <br />Describe Pruposed Work <br />Prolect Address (if knowr) <br />2ip <br />r�ne� wo,k: Pe,mn , <br />eiee� oem- • —si --�— <br />PublicWorksFec $ <br />TotalFea <br />LeesFool FeePaiC $ <br />Balence Due <br />Attach four (4) cupies of plane for proposed work - Draw to scale and note the following as applicable: <br />• Propertv Line= .• Centerline ol street <br />• Outline and dimensions of all exislir�g and • Indicate Norfh <br />proposed structures on the lot ! Show any proposed grading changes <br />� Ezisting and proposed ulllitie: • Show meacurements <br />S � �-3a �� <br />rnone <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259-581 5. <br />2 All work shall be performed in accordance with this permit and current Ciry ol Everett Design and ConsVuction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. betore you �ig. TOLL FREE � UMBER 1•$00•424•5555. <br />pvB�,c r�-�,�',fs ,�'; ;,�1,,—,�/�>,— 2f��� -;,r;�sU <br />Approved lor Consiruction <br />FINAL INSPECTION <br />Approved as Constructed <br />everelt � PUBLIG WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everetl, WA 98201 <br />Phone:259-8815 <br />/D`/ 1� % <br />r� <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />O <br />� <br />� <br />� <br />a <br />The u idersigncd owneUapplicant hereby agrees to hold and save harm- <br />-- less �he City ol Everetl irom any and all claims for damages, cosis, <br />expenses, or causes ot action that may arise 6ecause of installation <br />and maiNenance of the improvement or other rigM-ol-way use hereto <br />applied for and lurther agrees to remove same upon notice irom the <br />Date City and to replace public property damaged L.ereby. <br />Signatme o( F,o'�cant Date <br />WORK AUTi' - cD BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAVS TE PERMIT IS !SSUED AND TiiEFEAFTEF �S TJ <br />BE DILIG[i. �'URSUEO TU COMPLETION. THIS PEFMIT MAY BE <br />CANCELLED F3Y THE CITY UPON ANY STOPPAGE �f':VORK ON THI.i <br />PROJECT OV[R 90 DAYS DURATION. <br />