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��H{� <br />Q M <br />��� <br />�i f! <br />pH� <br />'+tl M � O <br />��� <br />��g <br />�` � <br />C" H <br />N <br />fA <br />(� ri <br />W w <br />O � <br />� <br />� �� <br />��1 <br />�l :`-�' <br />Date , / L `% .' � <br />ApPlication For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />PUDr¢WOW�Permn• •J ��" � <br />emu oroi . __ . <br />Pub�rt WorMe Fee <br />Tuteif�e s <br />LeHAp01 !en Fe�E s /� <br />B�ienceDue s 2L' nC _ <br />C(,:! ��'�'!l/i °�/ <br />Time Oil Company 2737 W Commodore Way SeatCle 98199 (206)286-4495 <br />Owner Madmg Atldress Cny 2ip Phone <br />Envira►�rtal Science & Enaineerira Inc 17411 PE Union Hill �, 1/71S.Lf_3�, 41A 93�52 (2761869-8?20 <br />qpplitant Mal�l�g Address City Z�p Phone <br />DescribeProPosed Work �rill, install, and perioc�ically sample one four-inch inside diameter <br />groundwater monitoring well in r,he sidewalk adjacent to N. Breadway. Well will be placed <br />to avoid utilities in easement as i <br />location shc�n on Figure 2. <br />Prol��� AddresSU� known) 928 N. Droadway, Everett� W/1 <br />will not be bl <br />AilaGh lour �4) eopiCS ol plan5 lor pron�sed worh � D�aw �0 SCale antl noie fhe IOIIOwing aS appliCabie <br />• Prope�ip L��es <br />• Gutline 2nd Aimensions ol all ensLng antl <br />propoSeA Slruclure5 on Ihe lol <br />• EMl,ting and pr000sed ulilitirs <br />• Cenledine ol sVeel <br />• intlicatc Norlh <br />• Show any pmPOsed 9raAing changes <br />• Show measurements <br />PERMIT CONDITIONS <br />7. All calls fOr Inspecbon shall be mede 24 hrs. in etivance- phone 259•8$i0. <br />2. All work shall Ue peAormed in amr�rd�nce with tnis permd and current Cily ol EverMt Deslgn and Conslructlon <br />Standards and Speciheations. <br />3. Call Location Undergrouna Serv�ce 48 hrs. bclore you dig TOLL FREE NUMBER i-800•a24•5555. <br />I ��'s� / ACKNOWI.EDG[MENi OF CONDITIONS <br />i)i <br />FINAL INSPEGTION <br />Approved as Const�ucted <br />PUBLIC WORI'S OEPARTMENT <br />3200 Cedar Street <br />Everell. WA 98201 <br />Pnone:259-8810 <br />W <br />� <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The unders�gnetl owner/applicanl here6y ayrees �o hold and save harm� <br />1e55 the City ol EverAtl Irom any and all claims Inr damages. cosl� <br />expenses. or causes ol action ihat may arise because ol instenation <br />and maintenance ol Ihe improvement or olher nghFobway use hereto <br />appl�etl lof and luriher agreCS to remov¢ Same upon noliCe Irom the <br />City a��d to re0lace pubGc property damagetl thereby. <br />/ �s�-�'7T�%f�(itfi�a'^' 02 % � ,>7 <br />Signatwe ol Applicant Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAVS OF DATE P[HMITIS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED 10 COMPLETION. THIS PERMIT MAY 8[ <br />CANCELLED B1' THE CITY UPON ANY STOPPAGE OF WORK ON TNIS <br />PROJECT OVER 90 OAYS DURATION. <br />