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DateJ�/��•��(J , .,_'. �� r�oi�cwo,wsoo,mn. � <br /> '�' �,? � / Application For mnq aen��• � - <br /> b � � PUBLIC WORKS PERMIT °°°°°w°,�=°°° — <br /> iulnlPee � <br /> Q H <br /> N lesz Fo�O� Fnr,oa:�.t $_ <br /> � � �' A,�:�.r� . .. 'j <br /> H z M _ ._. _ _-. -_- . <br /> K � Print or Type Only - — — <br /> ro � ro <br /> � N N , / /� /J/ � / . �r <br /> O �tl —���4��'��i4�/��ia� y(�'7/9 ��Py�n/M�A( /�/�' �t/P�f �i.----- ---- <br /> O N � Ow er � Mailing Address City up �"�...�,�.� <br /> H � � r/� r I �/ �f ('� / /���� ��� /� <br /> !+ y � _�/'�Vl • f��� ��ll��� r�'7��/ � 1/'j'� !'N i '-".4'y�J[l�--C�(,�/Q � S_}��:��/� <br /> b App il cant Mailing/.ddress Ciry / Zip Phonc <br /> �� <br /> N H i <br /> � N /� ��,,� -( n n� <br /> bC n Describe Proposed Work /'N-7_�J!���P�IJ'�. (��-'� �T7��rl.T�r ch �-� ---- <br /> � t� � _ <br /> O y <br /> N <br /> Prolect Address lil known) �✓ � `aJJ�vN (���� �/� � <br /> Attach lour�4)copies ol plans lor proposed wo�k- Draw lo scale and note the followin9 as applicabl¢ � <br /> • Property Lines • Centedine of sireet ♦^ <br /> • Outline and dimensions ol all eaisting and • Indlcale Noith y♦ <br /> proposed structures on the lot • Shov:any proposed gratliny changes <br /> • Existing and proFosed utilities • Sl�ow measuremenls � <br /> DO NOT WRIYF BELOVJ THIS LWE O <br /> PERMIT COIJDITIONS <br /> -. i.All calls tor inspection shall be made 24 hrs.in advance-phone 259•681 Q � <br /> � � 2.All work shall be pedormed in accordance with ihis permit and current City ol Everetl Desic�n and Construclion <br /> � C� � Standards and Specilications. <br /> 3.Call Location Underground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> I ��-� �U 1-�v��. i c_ �o«.ts�s {=��-M ��� �-���� i_'FU O <br /> I � r <br /> � i��e�.��--��� ���- <br /> � ��:i � /�c�/�� � <br /> ,� 0 <br /> , <br /> �,-, � a <br /> . s <br /> -t°�1 . ACKNOWLEDGEMENT OF GONDITIONS <br /> ' The undersi9ned owner/applicant hereby a9reus to hold and save harm� <br /> �I less the City ol Everett irom any and all claims lor damages. costs. <br /> expenses, or causcs ol aclian �hal may arise beCauSe ol inslall;�(ion <br /> I 1� and maintenance ol Ihe improvement or nther �i�htrof-way use hereto <br /> � � applied lor and lurther agrees to remove same upon notice Iwm the <br /> �\ �� Approved lor Construclion Date City and lo replace public pronerty damaged thereby. <br /> FINAL INSPECTION Date <br /> ApprOved as Conslructed Signalwe ol Applicanl ��t� <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> eveiett PUBUCWORKSDEPARTMENT 180 DAYS OF DAT[ PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CedarSlreet BE DILIGENTLV PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Evcrelt\NA 98201 CANCELLED BV THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259�8870 PROJECT OVER 90 DnVS DURA710N. <br />