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Date�l-�V ' <br />a.� � � - 7 - 22� S <br />Applicetlon For <br />PUBLIC WQRKS PERMIT <br />Print or Type Only <br />ng <br />Cily <br />���en.wc���re[�m?a�./ w/' 'C�/'i—''z]�v / <br />BIpO Onpl � .�(fJ�Qy� '�_ <br />! ' " <br />{`uELc Wo�k� fee <br />Toiei Fee S <br />I.eee �nUl P q Pu� S <br />B�i�nce �ue s Z�— <br />Phone <br />I'��` <br />pplicant MaiGnB Add�ess City Zip Phone <br />DescriGa Propoeed Work <br />Pro�ect Addreae (il Fnown) 8 � 1- � G�� Pv S�ft4�. � I,J A' <br />Altach lour (4) coples ol plany lo� proposed work • Draw to scale nnd nota �he fcllowing es �pplicablq: <br />� ProPcrty lines R Cenl=dine ol strert <br />• Outline ond dimenaiona of ell exlslinp end • Indcale Norlh <br />propoaed siruc�wes on the lol f dhow any proposed grading � nenges <br />• Existinp and proDosed utilitles • Show mens�irements <br />PEFMIT COIIPITIONS <br />1. All calta lor Innpectlon ehell be mede �� hra. In edvence • phono 259•8:510. <br />2. All work shell be peAormed In accc Jur��a �.rith thla permit and curreN C!ry ol Fveietl �eeiqn ard Cc �ebc-tion <br />Standerde end Speclllcatlons <br />3. Cell Locetlon Underpround Service 4B hre. belore you dip. TOLL FREE NUMBER 1•KiNi424•5555. <br />SF-NT ME'MO TO R'AN/W.�G/I�I��CD/N(j , <br />`� ,�; .3a yG <br />Approv Constru i ate <br />i <br />�.i� � <br />F�V L IN �ECTION � Date <br />Approved es Conetructe . <br />everett PUBLIC WURKS DEPARiMENT <br />� 3200CedarSlreet <br />Everel4 WA BB20t <br />Phone: 258•8810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />�� <br />� <br />The undersigned ownar/appliCant here6y eBree9lo hold er.d save harm• <br />less Ihe City ol Everolt frum any and all clalins lor damopes, costs, <br />e.penses, or causes ol aclion that mey arise becauae of inelallalion <br />end mnintenance ol Ihe improvemenf m olher righhol�wey use here�o <br />epplied lor and luriher agraes lo remove same upon notica trom the <br />City and lo replace publlc. properly damnged thereby. <br />Signat re ol Appl an Date <br />WORK AUTHORI FD BV TNIS PERMIT MUST BE STARTED WITHIN <br />1B0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFIER IS TO <br />BE DILItiE1�TlY PURSUED TO COMPLETION. THIS PERMIT MAV BE <br />CANCELLE D BY THE CI'Y UPON ANV STOPPAGE OF WORK ON THIS <br />PtiOJECT OVER 90 DA IS DURATION. <br />