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�8�e� Puni�cWorhefbrmn� �� /I � <br /> �� e'aa Deo� • �',�� <br /> Applice�tion For <br /> PCI�LIC WOL�KS PERMIT °""°`W°,`.`"° '7," `"' �, <br /> To1�1 Fee � <br /> �eu�pPl Poe P��C S — <br /> B�lanr,e Due 6 'rU ' e��� <br /> Print or Type Only <br /> � f'10A���. <br /> �L� .ld. � I uc'�7o�r�zzo„r s.�. `I�.�edc.�. 9�a_4;L.�'J� -G�ll l <br /> pWpp� Malling Address City Zip Phone <br /> �PEF4I �A�L'�L�J���.`fi��F/4���1����7�� <br /> 9,p�� �� � CO' , MxilingAddiesa Clty Zip Phona <br /> N. �.. <br /> Descrihn Propoaed ork --��e��.�'.—`.`t—�lL—� J��+'�U �� � <br /> ���-��1��_ —__ --_ — <br /> ---- - LLI <br /> Prolect Addrass(il known) ���'L � . c-A�,:,� __ � <br /> Atlech tour(4)cop�es of plens fa proposed work� Drew to scele end noto Ihe toPowing as epplicable: � <br /> • Properfy Lines • Cenlerline ol sVeel � <br /> • Outllno end dimenalons ol all axisting and • Indicata North <br /> propoaxd 8!ructures on the lot • Show eny proposed Brading chonges <br /> • EMisting end proposad utilitlea • Show measurements � <br /> DO NOT WRITE BEI.OW THIS LINE � <br /> PERMIT CONDITIONS <br /> 1. ,411 calle lor inspection ah�ll be made 24 hra. in ndvance� phone 2G9•Be�5. � <br /> 2. All wurk ahall be pedormed In accordence wi!h ihis permlt end current City ol Everett Dot:gn enA Constructi�n <br /> Standerds and Spaclllcetions. <br /> 3. Cell Locetion Underground Service 48 hrs. belore vou dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> � <br /> �p� <br /> �I <br /> � <br /> a <br /> ACKNOWLEDGEMENT OF CONDITION.i <br /> The undarsigned owner/nopi canl heraUy ugre�n!o hold end aeve he�m� <br /> � � � less the City af Everetl 'rom any end e,l dnlms lor demeges, costs, <br /> expenses, or causes ol nclion ihet mey arise because ol ins�xllation <br /> �� end melntenenca ol the improvement nr other righbof�way i�se hereto <br /> _�--'^7 ✓ <br /> � � k � <br /> / ���� _./. appliad lor end li�rther egraes to remove seme upon nuli x Ir m the <br /> ppfOVBd 10� .^.O118110CIlon � r Date Clly and lo repl,..- public rop�•rty demaped thereby.� /q��C� <br /> �� � _ / / <br /> � IN� � GFl.�__ , - y's _ � Sy' �i j� <br /> ECTION Date �'��i��� •--�._ <br /> ApprovAA ea Cons�rucled � ignel�re o A�plican � a� <br /> ' � WOR� AUTHONIZEU LY TIIIS PENMIT MUST BE STARTED VJITHIN <br /> everett PU[fLIC WOFKu DHPnRTMENT 180 DAYS Of DA7E °ERMIT IS iSSUED .^,�:C THEREAFTEF IS TO <br /> � 32U0 Ceoe�SIre�K BE DI'_IGENTLV PURSJED TO COMPLE'ION. Th15 PERMIT MAY BE <br /> Everetl,WI pf12i�1 CANCELLED BV THF<.'ITV UPON AN'!5*OPPAG[OF WORK ON THIS i <br /> Phono:75L-C815 PROJECT OVER 90 DA�S�URATION. <br />