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� <br /> � Dy�g,3�/�" �f Puciic worke Permn• <br /> Application For eiao.ooa�.+ <br /> PUBLIC WORKS PERMIY PubTa�FaaFae S <br /> �asa nooi.Fae va�a S _ <br /> Balanco Duo $ <br /> Print or Type Only <br /> �a �'% E {'�'_G� C•c_ �S"�� � • �o . .� �,���;= Gr��cTr �,l'd o 3 z � 1-93 r,f <br /> Owner Mailing Address City ZiP Phone <br /> Applicant Mailing Address City Zip Phone <br /> z <br /> 0 <br /> � � ` � <br /> DescribeProposedWork ��n 1���1'��� l'�Y� ��'��e �''c�'��-��-1' /L��r���-� m <br /> G <br /> �. �-. <br /> - W �' �' <br /> � � <br /> �, _ <br /> Prolect Address(if knowa) . -� �� � '�L� � o m <br /> � co <br /> Attach four�4) copies of plans for proposed work- Draw to scale and note the owin as applicahte: . � � � <br /> • Property Lines /� erli Y of sVe 9 � / � o m <br /> • Outline and dimensions of all existing and • I i ,ale orth J / <br /> proposed structures on the lot I• ho an pr ysed radin = -Z-� <br /> • Existing an d propose d u ti li ties • ho m s r e f n e n t � m .. <br /> I i � .o = <br /> DO N W ITE B W THI� /��1E� �/�X" � _ <br /> PERMIT CONDITIONS /y�� �/�� � O � y <br /> i. A l l c a l l s t o r i n s p e c t i o n shall be m de 24 r . � advan e- p e�1b9•881rr�. (� \ r� o � <br /> 2. A l l w o r k s h a l l b e p e r l o rmed in a ord ce ith t ' ermi t a d current Cit yp�v erelt Desi gn an d s t u c on � T n <br /> Standards and Specifications � (�/ /� --i m <br /> 3. Call Location Underground Servi 48 hrs. bet�re u di.TOLL FREE NUIV�BF�R� Sp0•424-55 m �., <br /> • a.-iy ,31,r (�,�sc �p uD Z �+ <br /> � „ {- a �, 4� O o r <br /> rlc'-") `� � 8 t(( Nr�ts' 4cr y ; N <br /> �, �, � y' / ( 'm <br /> ^ �`�ar�7"� lUd 6� �x�tn � � � <br /> �� lI � m <br /> a <br /> }\`V� �C � �1�: � sia�c � n <br /> Q• ac <br /> �— i,�) 4 l� l� k. � <br /> �� E t� I-" $ � �� O � <br /> _ <br /> - �-�z�� �.at a N <br /> ���, Z <br /> ���� ,� , � <br /> � (p Aer� w� ll. c�+�a �v ruc-. lc m <br /> ..j.u� d�--� I ACKNOWLEDGEMENT OF CONDITIONS <br /> 0 The undersigned owner/applicant hereby agrees to hold and save harm- <br /> — less the City of Everett irom any and all claims for damages, costs, <br /> � expenses, or causes of action that may arise because of installation <br /> and mainlenance of ihe improvement or olher right-of-way use hereto <br /> applied for and further agrees to remove same upon notice trom 'he <br /> Approved lor Construction Date City and lo replace public property damaged thereby. <br /> / �. I � - ��� �� - <br /> FINAL INSPECTION Date `i�-� �'U-! �' �v �� <br /> C.pproved as Constructed Signature of Applicant Oate <br /> everett PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST 8E STARTED WITHIN <br /> � 3200 Cedar Street 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett,WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Phone: 259-8815 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br /> � <br />