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Date � �_ �,,.,.�,,...., . "�/ --- <br /> �ppl�cdtion For �,��.:: o�:,, . �Q��" " n_7 _. <br /> PUBLIC iNORKS PERMIT Au�Totelpeefee s - <br /> Leu�op�he Pa�E S <br /> BalanceDue S <br /> Print or Type Only <br /> _�1CCd�-{ � �c n n � l�nv�P1 oD f���X�� �riArP77�' ����ri �i5-5�.3.s� <br /> Owne� �ti g Ad retl 55 C�ty Z�p Phone <br /> �Y• p <br /> �pp���a�� MaWng Atldress City 2ip Phone <br /> Desc�ibe P�oposed Work �N4H7 1 M�fn{lf_}J(/Nf MY S�h0 /i-�pyjvl�{��j(/�,� <br /> Project Address lil knownl — �7 a� CN����yt1 _d � 'NIYD , � <br /> Attach lov�(d)cop�es of plans 1or proposed wo�K� Draw to swle and note Ihe loliowing as applicable. � <br /> • Pronerty Lines • Centerline of sirent � <br /> • Oufhne and dimensions ol all eKis�ing snd • Indicate North <br /> proposetl structures on the lol • Show any proposetl qraAiny chanyes <br /> • E�isting and proposed utilities • Sf;ow measuremen�s � <br /> DO NOT N'RITG BELOW TNIS LIN[ O <br /> PERMIT CONDITIONS <br /> 1,All calls for inspection shall be made 24 hrs.In advance-nhone 259•8810. � <br /> 2.Ai:work sh;il be pertormed in aocordance with tM1is permit and wrrent Ciry ot Everett Design and Consiruction <br /> StandarAs anA Specitications. <br /> 3.Call Lowtion Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800•424-5555. � <br /> ��J� CcJc-�Y.� �f�2�u�/t�a� ��:�� O <br /> �'j./L (�'va�,=— � <br /> y -3��-qv N I <br /> � <br /> a <br /> ACKNOWLGUG[MENT Of CONDITIOkS <br /> 1he undr_rs�yned owneVapPlicant hereby agrees to hoiG an0 save harm� <br /> ir.s; the C�ty ol Eveiett Irom any and all claims lor damages. custs. <br /> expenses. or causes ot action ihat may arise because o! insta�lation <br /> and m;�intenance of the improvement or othe� nghl-ol�way use herelo <br /> apP�ied for and lutther agrees lo remove same i�pon notice �som thr <br /> Approved for Construction Date City and lo repiace public property damagetl theieby. <br /> FIYAL IN3PECTION Date <br /> Approved as Constructed Signature ol Applicanl �a1e <br /> WORK AUTNOPIZ[D BY THIS PEFMIT MUST BE STARTED WITHIN <br /> everett PUBLICWORKSDEPARTMENT 1g0 DAVS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CedarSireet BE DILIGENT�V PURSUED TO COMPLETION. TH�S PEP1.11T L4AY 8[ <br /> Everett WA 98201 CANCELL ED�Y THE CITY UPUN ANY STOPPAGE OF V�C��K(�.N THIS <br /> Phrne�.259-8810 PROJECT OVEf7'.30 OAYS DURATION. <br />