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� <br /> ��.-� N,.��,�w,�.=N -�'%-/�' <br /> Date ��� <br /> tlm4 Dno� + . - - - <br /> qppl�ca'..on Fo- <br /> .__'_.__-_____--___-. ____.. <br /> PUBLIC WORKS PERMIT �°°'"w°""ee _ <br /> roia�Fee s--- <br /> 'e55 flp�l Fne Vaid $ / -- <br /> I Balanre Du¢ $ �"�C�� <br /> �_ <br /> Print or Type Only <br /> ��r� �.��5t-I�m ��� �r�? � �z a�' i'Y�ll ri �.� QB�� <br /> Owner aiHng Atltlress uty Z p Phone <br /> 2�f—llX�1 <br /> ppphca�t Mailing Address Gity Zip Phone <br /> Descnbe Pr�posed Work �r l.L�-����� �' — <br /> W <br /> P�olect Atldress lif known) ���� - �a^� �� �� pm� — � <br /> Attach four 14)copies of plans tor proposed wo�k- Draw to scale antl note thP following as epplicable: � <br /> • Property Lines • Genterline of sireet � <br /> • Outline and dimensions of all existing and • Indicale Norfh <br /> pioposed structures on t�e iot • Show any proposed grading changes <br /> • Existing a�d p�oposed utiGties • Show measurements M <br /> W <br /> DO NOT WRITE BELOW THIS LINE � O � <br /> PERMIT CONDITIONS <br /> 1.All calls foi inspection shall be.made 24 hrs.in advance-phone 259-8810. � <br /> 2.All work shall be performed�n accordance with this permit and current City of Everett Uesign and Constmction <br /> Standards and Specitications. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800-4a45555. � <br /> T. �LGr�-G'Lt*iC� ��t�PC cl<z.c y�i "�p�/� �.�C[ /"'�C!/Ri'. O <br /> .CP/lrvG'�P CC4�� .QL�GG�^/ G2 S�-G(�<-s✓.2�jU !!�E�r��4,(.l?�.� 2L9+.d' � <br /> V <br /> /Ze�acc� �uhf.L m�w c//�c<<ecc.a y f?�i�✓ G��� ,�a.,�`�� �3t�7 <br /> O N <br /> � <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrens ta hold and save harm- <br /> less ihe City of Everett irom any and all claims for damages, costs. <br /> expenses. or causes of actio� that may a�ise becauze of installation <br /> ` /J / ' p,;) — and maiNe�ance ot [he improvemenl or o�her righFot-way use he�eto <br /> E>7 �� applied for and further agrees to ramove same upon noiice from the <br /> Approved for Consiructi � �a1e City n �ace public property dama9ed ihereby. <br /> / ` .z -�- � <br /> �a- !� , <br /> f�i�+s� INSPECTION Date � Date <br /> hpproved as Constructed Signature of Applicant i <br /> WORK AUTHORIZED BY THIS PERMI? MUST E STARTED YJITFiIN <br /> everett PUBLICWORKSDEPAPTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAfTER IS TO <br /> � 3200 Cetlar Street BE DILIGENTLY PURSUED TG COMPLETION.THIS PERMIT MAY BE <br /> Everett WA 98201 CANCELLED BV THE CITV UPON A�'V STOPPAGE OF WORK CN THIS <br /> Phone:259-8810 PROJECT OVER g0 DAYS DURATION. <br />