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o .� <br /> oe�e 4i6i9a ' TO P�TIN�_ zy, �,, _ P�o,.�Wo,,.Ps��z�a� ��3S <br /> Appllcatlon Fo�r e�ao oeo� • _ <br /> PUBLIC WORK� P�RMIT °°°:o,:FeeFe� : <br /> � <br /> GLess�po�iee f.�d S—�-��— <br /> Print or Type Only ¢� g S � � c� �i � � � � Bm�ce o�e f-!�(/ <br /> O T �O �J � tl1 CJ � II1H (D <br /> 3 M M M N N V] M t�^ <br /> Withere Conetruction 21511 45th �1ve S�E'" Bothell 9802Y L,21-4594 <br /> CJ J <br /> Owner MailinB Me 2 �1 v� �n Y�p Phone <br /> � � �? � � � � � ��s' � � � <br /> OhTiER � dS� S� � S�'' a� <br /> Applicent Mailing Address City 2ip Phone <br /> DuscrlbeProposed:vork New house - Basic 164 <br /> � -- W <br /> Pro�acl Address(if knownl 1323 E Caeino Rd ,�,p.�r.�� n....�,.. .,___ m �, � <br /> Allach lour(4)copies of plans for proposed wmk- Draw fo scale entl note Ihe following as applicable: � <br /> • Froperty Lines • Centerline ol sireet � <br /> • Oulline end dimensions ol all existing and • Indicele North <br /> proposed stnicture�on the lol • Show any proposed gratling chenges <br /> � Exisling and proposed utllitiea � Show measu�ements � <br /> DO NOT WRITE bELOW TMIS LINE O <br /> PEHMIT ;ONDITIONS <br /> �.All cUlle for InepeCtlOn eh011 be mOdB 24 hB.In edvenCO•phOnB 259•8810. � <br /> 2.All wark ahall be peAormed In eccordence with Ihia permit and currenl Clty ol Everett Dealgn end Conelructicn <br /> Standerda and Specllicetlone. <br /> 3.Cell Location Underpround Service 4B hre.belore you dig.TOLL FREE NUMBER 1•800•424•SSSS. � <br /> . O <br /> � <br /> � <br /> O <br /> a <br /> p�p, ACKNDW�EOGEMENT OF CONDITIONS <br /> C�� .y�/9ir The undersigned ownen,pplicanl hereby egrees to hold and seve harm� <br /> �1 ° less Ihe Cdy ol Eve�e�t trom any xnd all clelms lor demages, costs. <br /> ` / ezpenses. or causes of ar,,ion Ihat may erise because ol mstellation <br /> / �G� �/ /,Q,/�// end maintenance ol the improvement or other�ight�ol-way �•se here�o <br /> l-� � � �f� ap � or and lurt r eg�eas to remove seme unon notice Irom Ihe <br /> Ap- �ed I nstrucli n ���er y a to replaCa p bhc property damaged thereby. <br /> � � ,� �1.� - �o-� <br /> FI t I E TION D le <br /> Approved as Conslructed S�gna e ol Appli t Dele <br /> � PUBLIC WORKSDEPAFlTMENT WORK AUTHORI2ED BV THIS PERMIT MUST BE STARTED WIIHIN <br /> 3200CaderStreel 1B0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everelt,WAB8201 BE DILIGENTLY PURSUED TO COMPLETION. TfcIS PERMIT MAY BE <br /> Phone:258-8910 CANCELLED BY THE rITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAVS DURAfION. <br />