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Date�Z � <br />Application For <br />PUBLIC �lVORKS PERMIT <br />Print or Type Only <br />P1a��,o.� Ld.,t�, <br />Owner <br />SAMt �1 S�oV <br />Appiicant <br />Describo Proposed Work S <br />Prolect Address (if known� _ <br />� 5 s y�- 6 �'a <br />Meilinq Address <br />Address <br />r �w/�`/� S & � rs <br />City Zip <br />City Zip <br />PuElit Works Permii � �� �'�/ <br />emB.oeoi..�� /5��9�_ <br />Pu011c \Vorb Fe�� <br />To�al Fea $ — <br />Less Appl Fea Pa.d $ <br />eaia��a o�0 5 _a0. L�b <br />%70/ 0 <br />— `/k'G - S�� <br />Attach four (4) copies of plans for proposed �.uu�k - Draw to scale and note the following as applicablo: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <br />propoaed structures on the lot • Show any propoced gradinp changes <br />• Ezisting and proposed utilities • Show measurements <br />PERMIT CONDI'i IONS <br />t. All calls for inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All work shall b� performed in accordance with this permit and current Ciry of Ever?tl Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1-000•424•5555. <br />���. �,, �//�� <br />Approved for nstruction Date <br />! /G+-/T-Fr' <br />F.iN INSPECTION Date <br />Approved as Cons�ructed <br />everett PUBLIC WORKS D[PARTMENT <br />� 3200 Cedar SVeet <br />Everelt, WA 98201 <br />Phone: 259-8815 <br />ACKNOWLEDGcMENT OF CONDITiONS <br />� <br />� <br />O <br />a <br />The undersigned owner/applicant hereby agrees lo hold and save harm• <br />less tte City ol Everett irom any and all claims for damages, costs, <br />expenses, or causes ol aclion thal may arise because of instaliation <br />and maintenance of the improvement or other right-ol-way !�se hereto <br />applied lor aod turlher agrees lo remove samr. upon notice Irom the <br />City and w replace public property damaged thereby. <br />��"vl YJ�%t.wy, (o�Zs' P._,�� <br />Signature of AppLcant Dal^_ <br />WORK AUTHORIZED BY TFIIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF OATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PUFSUED TO COtiIPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />z <br />0 <br />-i <br />c� <br />m <br />�.. <br />-� � <br />�., --� <br />tn x <br />m <br />0 <br />mo <br />c'� <br />O 3 <br />--i z <br />x --i <br />m <br />.. <br />cZ <br />n -i <br />.r. _ <br />� <br />< N <br />� <br />Ta <br />3 <br />—� m <br />x <br />m �-+ <br />N <br />or <br />�m <br />3 1Nn <br />m <br />z c� <br />.im <br />n <br />z <br />x <br />n <br />_ <br />� <br />_ <br />� <br />Z <br />0 <br />� <br />c=� <br />m <br />