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Date 4—g—a� <br />Application For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />ZnJ aslt�s� � T�nc. . <br />���f o, VO'�S�Y�U <br />Applicant <br />Describe Proposed Wor��� � <br />Project Address (if known) , � � <br />r�namng Haa <br />,� �. <br />Mailing <br />� �J �"�" <br />cuv <br />Tol..�.-� <br />City <br />7 <br />Pu01i� Wo�Me Parmtl • // `�' �� O <br />Bltlp. Dapt • _— <br />Pubt¢ Works Foe /OO <br />Tutnl Feo S <br />, �eSaApP� Ra PaiJ 5 �_ <br />eoio��o o�� 5 1O0 <br />� <br />q�z�e <br />Zip Phone Z <br />9�.oco Z5a-�V�-� � <br />ZiP Phone �,',� <br />Atlach (our (4) copies ol pla lor propo work - Draw to scale and note lhe followinc� �s applicable: S/�ej�"G /S //1/ <br />• Properly LineS • Centerline of street 7 /� <br />• Outline and dimensions of all existing and • Indicate North 7�U/ L'iY.l�cf'a� <br />proposed structures on lhe lol • Shuw any proposed grading chanyes U <br />e Existing and proposed utilities � • Show measuremenls <br />PERMIT CONDITIONS <br />1. All calls lor inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All work shall 6e performed in accordance with this permit and current City ol Everelt Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. 6elore you dig. TOLL PREE NUMBER 1-800•424-5555. <br />� ��� �'/��T-9 CC�i�� — <br />Approved as Constructed <br />eveiett PUBLIC WOF;KS DEPAFTMENT <br />� 3200 Cedar Sireet <br />Everett, WA 98201 <br />Phone: 259•8815 <br />` <br />� <br />� <br />� <br />0 <br />� <br />ACKNOWLEDGEMENT OF CONDI?IONS <br />The undersigned owneUapplicant hereby a9rees to hold anh s�ve harm- <br />less the City of Everett Irom any and all claims for Aareen�s. costs, <br />expenses, or causes ot action that may arise 6ecause of i��.,tallation <br />and maintenance ci the improvement or other right�obway use hare�o <br />applied tor and �urther agrees lo remove same upon notice from ihe <br />Cily a o replace ublic roperty damaged thereby <br />V`c�.— � -'�QSi L� — � - gJ �c• <br />•.�. � . .9..s�.� 4 - 3- aSo <br />Signature ol Applicant � Datc <br />WOFK AUTHORIZE� BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATG PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BV THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATIOIJ. <br />� � <br />'� ---� <br />N 2 <br />0 <br />m <br />ca <br />m o <br />t-� <br />O 3 <br />m <br />i —�i <br />m <br />�-. <br />O Z <br />c <br />a -i <br />rx <br />.. ... <br />� N <br />t <br />�'1 <br />O � <br />T 3 <br />�m <br />x <br />rn.. <br />v <br />N <br />or <br />nm <br />c �n <br />mN <br />z c� <br />—i r <br />• m <br />a <br />a <br />-a <br />x <br />a <br />z <br />� <br />x <br />N <br />Z <br />O <br />�--I <br />.-� <br />C'� <br />m <br />