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Date_��/� /Ofi <br />� i i- <br />Application For <br />I�UBLIC WORKS <br />Print nr Type Only <br />Owner <br />f,Aailing <br />Describe Proposed Wo�k <br />Projecl Address �il known) <br />� <br />ti <br />PEt�QMIT <br />OO <br />tl p p� p �7 <br />� InK�1�JS Ol <br />��j O M M � <br />.�i M N M � <br />Attach lour (4) copies ol plans lor proposed work • Draw to scale and note <br />• Prouerty Lines <br />• Outline and dimensions of a�l exis�ing and <br />proposed s�ructu�.;o on ihe Icf <br />• Existing and proposed utililies <br />Icr <br />everelt <br />� <br />Pubi¢ Wm�s Pcrm[[�]]�i ��^� ���/� <br />Biaq oeo� • .�[�/_p�j�_57� <br />PublitWorksfee / <br />Tolalfee S <br />LeesApP� FeaPaid �i ..—y� <br />BaianceDue S .�"]=� <br />��iy,�,,,� <br />Phona <br />Phone <br />lollowing as app!icable: <br />• Cen;erline ol street <br />• Indicatc North <br />• Show any proposed gradinc� changes <br />• Show measurements <br />PERMIT CONDITiOMS <br />1. AI� calls for ir=aection shall be m de 24 hrs. in advanco - phone 255•8810. <br />2. All work shall Ge perlormed in a:ordance with this permit and currer�t City of Everetl Design and Construction <br />Standards and Specilications. <br />3. Call location Underground Service 48 hrs. befor� you dig. TOLL FREE NUMBER 1-800-424•5555. <br />4, 7fl�v,�s -�Z� �. �zc-�/U�ti�.; 1�r�57 �'x= ��l�rr�J �avt� <br />l �-�2 Di<�,z7� ci -��,�v�r�-=��� ,?�� ic,� � � t1,v�c ��c,r�� �%�-L <br />PUBLIC VJORKS D <br />3208 Cedar Street <br />Everet6 WA 9ffi01 <br />Phone: 259�8810 <br />--:fi G -y <br />-� _,t/� /, <br />Trn-.,.- <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />/� <br />� <br />� <br />O <br />1'� <br />� <br />� <br />a <br />The undersigned owner/applicant hereby agrees to hold and save haim� <br />less ihe City of Everetl Irom any and all claims for damanes, costs. <br />expenses, or causes of actron that may arise because ol installation <br />�and maintenance ul ine improv�ment or other right-of-way use hereto <br />applied lor and urther agrees to remove same upon nolice hom ihe <br />City and to r ce public p y maged thereby. <br />! <br />/DZ- o <br />� ture of App icant Date <br />WORK AUTHORIZED BY iHIS PERMIT MUST BE STARTED WITHIPJ <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PEf7M1T MAY BE <br />CANCELLED B1' THE CIT'; UPON ANY STOPPAGE OF WORK ON Th+iS <br />PROJECT OVER 90 [?AYS DUFATION. <br />