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Date 5,�/O 7 Pvn'n Worwe Pe�mit� J�L �/`�'�c <br /> Applicallon Fm <br /> Biap �eo� • � �Li— <br /> PUBLIC WORKS PERMIT °°°:o,:Fee�ee s <br /> �ees�oo��ee veio S_„�—�— <br /> B�I�nce�m s`v� <br /> Print or Type Only <br /> �z��/�OuJ V A✓' A7 �[i Y .3 U� C/ ) �✓(� i P� �3 ��� <br /> Owner � Mailing Address City Z Phone <br /> _S A W� �. <br /> App�lcant Melling Add�ess City Zip Phone <br /> Deacribe Propoaed Work /�/QlA1 �,u��e k a,�L e. -- ___ <br /> -_J � w <br /> Pro�ect Addresa lif known� � �([ /' .�/Yd _ � <br /> �c. O.�!'. � <br /> Attach four(4)copies ol plans lor proposed work� Drow lo scele end note the iollowinp a5 applicable: � � <br /> • Properry Lines • Centerline of street � �� <br /> • Oullina end dimensions of all eKisting and • Indicete North <br /> proDosen alrutturea on Ihe lot � Show eny proposed grading chenqes � <br /> • Exlating end proposed ullliliee • Show meesuromenis � ' <br /> DO NOT WRITE BELOW THIS LINE O �' <br /> PERMIT CONDITIONS <br /> 1. All cella br Inepectloi�shall be mede 24 hrs. in edvc:ice- phone Z59•881 5. � <br /> 2. All work ehell be perlaimed in eccordance with this permit and curreN City oi Cverett Design and Construcllon <br /> Standerds end Specifications. <br /> 3. Cell Locetion Undergrourd Servicr.48 hrs. belore yuu dlg. TOLL FFEE NUMBER �•800-424•5555. � , <br /> O <br /> � <br /> � <br /> � <br /> a <br /> ACK'JOWLFDGtMENT OF CONOITIONS <br /> The undersigneA owner/appllr.en�hereby oyrees�o hold and snve hn�m• <br /> _��� -- less the City d Fverelt from an� and ell claim:: lor tlemaBas, costs, <br /> �' expenses, or causes of eclion hie� mey erise bec�usr. of m�tallalion <br /> i ��� end maluten�nce of �he impiovenient or other ripnt �ibwey usc hnreto <br /> �"iy �`'� �� applied lor Bnd fw�her egrees tn remOve Same upon no�ir,e irom the <br /> ed for Ge i �- Date City and to replace public properly damaged ihereby. <br /> � �� ,�'�j . // ���^ <br /> FINAL I SPECTION Date � / ' '� '� ' <br /> Approved es ConslructeA S nature oUkbPlicnnt � Date <br /> everett PUBLIC WORKS DEPARiMENT WORK AUTHOiiIZEO BY THIS PERtit1T MUST BE STARTED WITHIN <br /> � 3200CednrSlreet 180 D41'S OF DAiG PERMIT IS ISSUED AND 1HEREAFTER IS TO <br /> Evere',L WA 98201 BE DIUGENTLV PURSUED TO COMPLETION. TfiIS PERMIT MAV BE <br /> Phone: 259-8815 CANCELLED BV THE CITV UPON ANV SinPpAGE OF WORK ON TFllti <br /> PROJECT OV�q g0 DAVS DUi7A71CN. <br />