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` r <br /> Date 'S" ��/l�`� e ;,� � <br /> ✓V P�bim Wm�s P.rm�1• � <br /> �7 �1 r� <br /> � Application For emq oeo�.• � L_ <br /> PU�LIC WORKS PERMIT PuOL,�WO�F6Ftl! �Z,_ <br /> .o�a�F�� s <br /> p leu eoa�Fee aa�a S <br /> Print or Type Onl� "� � � 'g' `n` � � o � a o'`. BeiancoDue s <br /> O� ++ .� M fY M I!7 O O C�l O� <br /> 1J7 CJ �O 6l .+ u] N +� O M �O �7 <br /> .r M M CJ M u� CJ M P O <br /> ,^,.�^ ~ [�l ~ N f•. � N I� M N <br /> � / �. l.� �,�a�c��(�27y 8a�7��� <br /> Owner � g � � � S��Rp���� � � � � Cit ZiP " Phone - <br /> = u� wo �- o � tiw <br /> �-I t�.1 i`'�l�� a o��-�'i W�� a ��,.,rZ_'� (�� "'"� ���P1/�(.P �'i�GO� <br /> Applicant Maihng Address City 2ip phone e ��-7 .-� ��� <br /> ,� ^ C�� !Tx <br /> Describe Proposed Work ����t-��2/l��� <br /> Project Adtlress(if known) OZ -� CO� '/ � <br /> Attach tour(4)copies of p�ans lor proposed work-Draw to scale and nole the following as applicable: � <br /> • Property Lines • Centerline of streel � <br /> • Outline and dimensions of aIl exis�ing and • Intlicate North <br /> proposed structures on the lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1.All calls fo�fnspection shall be made 24 hrs.in advance•phone 2S9•8810. � <br /> 2.All work shall be peAormed in accordance with this permit and wrrent City ot Everett Design and Constructlon <br /> Standards and Specifications. <br /> 3.Call Location Underground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1-800•424•5555. � <br /> � �.-ar �����,�s o��e� �-z 9 -�8 � <br /> s. 67 cva�-� r�'rQ , r� (8 '' ,S r�,�vi;^�� �',� /6��� 7" <br /> �d��'7/ U�r`cr+e. �-�Y/'�/l/c�lJ D� �c C��.�+�, �1 � <br /> /S G�� / (� <br /> � <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm- <br /> less Ihe Cily of Eveietl Irom any and all claims for damages, ccsts, <br /> exGenses, or causes ol action Ihal may arise because of installation <br /> � jv --7�� and maintenance oi the improvement or other right•of•way use hereto <br /> �� applied ( nd lUrther agrees to remove same upon notice trom the <br /> ppfovetl� Con-y cti Dale <br /> � / City and:to repl ublic properry damaged ihereby. <br /> FINAL INSPECTION Dale �- ' ,.1 / �/�� <br /> Approved as Construded Signature ol Appllcant � Date <br /> everett PUBLIC WOP.KS DEPARTMENT WORK AUTHORI2ED BY THIS PERMIT MUST BE STARTED W!7HIN <br /> � 3200Ce0aiStreet 180 DAYS OF �ATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Ever��t,WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone:259�8810 GANCE�LED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />