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rr <br />Date ����.I�'�3 <br />� <br />Applicatlon For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Pomuc wmts vMmn • �+ �iD <br />eiaaveM � <br />Pua1c Wo�u Fee : �Q—__� <br />TmW Fea <br />�� <br />leso MW Fse P�fa S <br />9ah�+ceDue s ��" � � <br />� <br />' .��..___ Gi1V uY •..�'"_ <br />Proiecl Address Id known] <br />Altach four (4) coples oi plans 1or proposed work- Draw to scale and nole � C�nterline ol street�ble: <br />• Property Lfnes • Indicate North <br />• Ouitine end dimenslons of all existlng end � Show eny proposed grading chan0es <br />�roposed structures on the tot � ShoW measuremeMS <br />• Exlating and proposed utllitles <br />PER�aIT CONDITIONS <br />1. All calls tor inspection shell be made 2a nrs In advanca • phone 259•8815. <br />L. All work shall be pedormed M accordance with this permit end current City of EveYelt Design and Conslructlon <br />Standards a�d Speciflcatlons. <br />3. Call Location UnderBrountl Service 48 hra. belore You tllg. TOLL FREE NUMBER 1•800•424-555 . <br />�Q���n �. u G�a � b w�+av� � t v� Cw��y C� a.�. JG <br />, Ex��►,�� � i 1 <br />�e..�o� . <br />�� 7� IwN� PGe't�Cw Or V'Mt NC'w <br />, �•j�.e P.�..b1� /�..,+ w.,�.. t- b. <br />1...:.��.. <br />r °w °.Q� <br />W��IM <br />o� ����+� S? <br />( ' �}..-,.�..�1.�� tn. v..� �.,�. i�+-a <br />��'�� a.l t w. ..�..�+:s- <br />' �-ra�". `?_'���. �t ► i"'t 1. �o ..1...a .1SL . �' <br />�f �v t w�.N w 1��w+a o�1 ��w/1Q- ew�^� Gt�� �r.X. <br />� <br />LJ <br />� ppfoved ior Construcli <br />� �/ / .f.-f -i^' -- �', �� <br />ppproved as Constructed <br />everett PUBLIC WORKS DEPARTMEWT <br />3200 Ceder Street <br />(� � Evorett, WA 98207 <br />phooe; 259�6915 <br />L/�j <br />Date <br />� <br />O <br />� <br />N <br />O <br />a <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undareigned owner/epplicanl hereby egreea to hoid end eeve harm• <br />less the City of Everell trom any and aU clelms tor demapea costa <br />oxpenses, or cauees ol action thei mey Brise because ol Insieltetipn <br />end meintenance ot the imOrr,vement or olher ripht•of•wey uee herelo <br />applled lor and !uAher agrv�s fo rem e eme upon notfca Imm the <br />..,...r_:�.l.]..i��e..��hu-oKi6E'Ivd a dthereby. <br />i alure ol AppllCant Date <br />WORK AUT}10FI2ED HI� PERMIT MUST BE STARTED WITNIN <br />/BO DAYS OF DATE ERM1T IS IS5UED AND THEREAFTER IS TO <br />BE DILIGENTLV PURSUED TO COMPLETION. THIS P[RM�T MAY 8E <br />GANCELLEQ BY THE CITV UPON ANY STOPPApE DF WOPK ON THIS <br />PfiUJECT OUEf� 90 DAYS DURA710N <br />�� <br />C—J <br />J <br />.. <br />