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Date_�L �`�� <br />TO pO�T���r <br />• Applicatlon For <br />� PUBLIC WOROCa PERMIT� <br />Print or iype Only <br />� -�e.l�El <br />, <br />:1l sg,a at <br />/ <br />i� 7 PuDlie Worh� Pe�rt�t • O V <br />" ��7 �� iaa oao�.. <br />Putl¢ Worx� Fse <br />ToulFee s <br />La�a �pD� iee Pa�A S_ . <br />0�i��cr U�e S � <br />Zip <br />� <br />G <br />�escribe Proposec' Work <br />Project Address (il knowr) <br />Address <br />� <br />Attach fow (4) copies of F,lans lor proposed work - Draw to swle and note the Ioilowing as applicable <br />• Property Unes • Centerline ol slreet <br />• Oulline and dimensions ol all existing and • Indicale North <br />proposetl stru:tures on the I�t • Show eny Nroposed greding changes <br />• Existing and proposed utilities • Show measurements <br />PERMIT CONDITIONS <br />1. All calls tor inspecllon ahell be made 24 hrs. In advance • phono 259-8810. <br />2. All wo�k ahall be periormed In accordance with this permit end current Clty of Everetl Design and Conatruction <br />Standarda and Specificatlons. <br />3. Call Location Underground Service 4B hre. before you dig. TOLL FREE NUMBER 1•800-424•5555. <br />�, ,p�;,re�,�� (�w U-4� � ��l _ s �d�a � k �� =�3c�(� , <br />,� <br />Approved as Ccnstructed <br />��r�l� PUBLICVJOFKSDePAR7MEAT <br />/ � 3200 Cedar Sireet <br />� EveretL WA 90201 <br />Phone:258-8810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />�� <br />W <br />F� <br />� <br />� <br />� <br />� <br />a <br />The undarsigned owner/applicant hereby egiaes to holo and save harm- <br />less Ihe City of Everelt irom any and alt clalms lor damages, costs, <br />azpenses, or causes ol action that may arise because ol Installation <br />and maintanance uf the improvomont or olher right•of•wey use heretu <br />applied lor and further agraes to remove eeme upon nolice from the <br />City and lo replace public proporty damaged thareby. <br />J� �� 93 <br />Signature of Ap nt Date <br />WORK AUTHO 12ED BY THIS PERMIT MUST DE STARTED WITHIN <br />1B0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TG <br />BE DILIGENTL� PURSUED TO COMPLETION. THIS PERMIT MAY BE? <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DUflAT�ON. <br />