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��� <br />H <br />GHN <br />H�� <br />fC C] <br />H ?1 <br />�HhO <br />Vi rH <br />C�1 O ti1 <br />� H <br />��g <br />�,� � <br />t"y� <br />HH <br />N <br />g�� <br />�Htn <br />HOfn <br />I +w <br />'I �•���I <br />c���,� b� �'-�T <br />oate 9-�9_Bs <br />Appiication For <br />PU�3�.IC WORKS PERtI�C@T <br />Print or Type Only <br />f�U <br />Owner <br />Address <br />p� .30c�' <br />r�oei¢ woe•.s Pcima • �/ � <br />aieq 000��* — <br />Gub�m Works Fee s <br />Tote� Fae <br />�en�noo�F�ena�as �9no <br />Balanco Dve g <br />C�a <br />3� <br />Phone <br />S�. _��S 1%� -�P cJ/a1v1� /-1 Q�rn �' Phone <br />Mailing Address C��Y Z�P <br />qpplicant <br />r -� 1_ ��c.—/� ,n-Rsx.-. O a � n 5 <br />Describe Proposed Work �!'� �� T � r � <br />Proied Address (il known) � — ��n�' �"���f <br />/ <br />Attach'om (4) copies of plans lor proposed work - Draw to scal� and nole Ihe lollowing as applicable: <br />• ProOerty lmes <br />• Outline and dimensions of all eaisling and <br />�roposed struGtures on Ihe lol <br />• Ezisting and proposed utilitics <br />• Centedine of St�eel <br />• Indicate NOAh <br />• Show any proposed grading changes <br />• Show measuremenls <br />PERIv11T CONDITIONS <br />1. PII calls for insper.tion shall Ue made 24 hrs. in advance � phone 259•OB1 5. <br />2. All work shall be pedormed in accordance wi�h Ihis permit and cunent City ol Evur.lt Desion and Censiruction <br />Standards and Specifications <br />3. Call Localion Undergrouiid Service 48 hrs. hefore you d�g. TOLL FREE NUMBER 1•800•424•5555. <br />f� S:f_ �ET /S iu BE �CEf�%r C� �an� �a.T <br />ACC Tin�ES.. <br />,, j' q,v�' A/ECESSe �y r/'.�'rS.n ti� C O,</.r�['O � ! c G'z� <br />noiv� As D,,nE-�rEo b'y ;,,�- ,���,;�,< <.c.�c�,�,ts <br />JirJ.Sf'ECia.�. , <br />FINALIN�"iP`GIIUf�' �� ( � <br />Appmved as Constructed <br />everett PUBLIC l'VORKS DEPARTMENT <br />� 3200 Ceoar Strect <br />Evere�t, WA 98201 <br />Phone: 259-8815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />�w <br />_ / <br />Z <br />O <br />The undersigned owner/applicaN hereby agrees to hold and save harm� <br />less Ihe City of Everett trom any and all claims for tlamages, cosis, <br />expeeses, or causes ol action Ihat may arise because ol installation <br />and maintenance ol lhe improvement or olher rigM-oi�way use herelo <br />applied for and furiher agrees to remove same upon notice irom the <br />City and lo replace public property damaged ihereby. <br />.,� �......`J ...-. _ _.. <br />g�RO YS OOF DATLD-- PERMIT ISEISSUED AND NEREAFTER ISHTO <br />BE DILIGENTLV PURSU'SD TO CQ!�IPLETION. THIS PERMIT MAY �E <br />CANCELLED BY THE:.I1Y Uf-ON A;�Y STOPPAGE PF WORK ON THIS <br />PROJ[CT OVGR 7U DA'!S DUfiATION. <br />