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,, <br /> :.lwcY .. � I <br /> '°� � 2 /Z 8 <br /> � ^'A'- Puouc worb Permit• <br /> D8f@� /J . . eiaa o�oi •— �, <br /> Application For � <br /> PUBLIC WORKS PERMIT PueTotrFee�e� § ' <br /> Lcis AOPI.Fea�aitl 5 R <br /> Balance Oue S `" �C O <br /> ��� Print or Type Only /�._�-,r�° - <br /> �y On2-�'�Z`1o/�,,��/ <br /> A x �.— i�y � c� <.�o��,�✓ i�v���-r 9�a��� 3 a�- y y 3� <br /> ��V~7 �//'1 �'7�C�,5 �/Jll� � C IY ZiP Phone <br /> � Owner Maihng Address � <br /> O� H� � M�� �Mailing Address Cily Zip Phone I' <br /> Applicant <br /> � i� :A k 3� ti,oaL <br /> p Describe PraPased Work <br /> 3 a�� � -� <br /> HC /•'ST i�T - O✓c. o' Go-� J�1/J <br /> " �'g W <br /> n� � <br /> r p.i y Project Address(il known) ��'�'i f d 5 � <br /> /�U✓l' � <br /> N — <br /> � �"� Altach four(4)copies ol plans�or proposed work•Draw to scale antl nole ihe lollowing as applicable: � <br /> q dG y • PropertY Lines • Cenlerline of street <br /> 3 Ci7� • Outline and dimensions of all existinc�and • Indiwte North <br /> j proposetl slruclures on the lot • Show any proposed gradin changes <br /> • Eaisting antl proposed ulilities • Show me2suremenis M <br /> H O fNA W <br /> DO NOT WRITE BELOW TNIS LINE <br /> _ . ..3c'c- �_�,. <br /> PERMITCONDITIONS L���y � <br /> 1.All calls for inspection shall be mado 24 hrs.in advance-phone 259•8810. <br /> 2.All work shall be pedormed in accordance with this permit and current City ot Everett Desiqn and Conslruction <br /> �� Slandaid:and Specilica�ions. <br /> '�.. „�' 3.Call Location Underground Service 48 hrs.betore you dig.TOLL FREE NUMBER 1•800-424-5555. . � <br /> , c'q SN O <br /> i �� <br /> (.��. tf /J(.�^ L �(G:� SZ-. , l, C�f, .. ..., �:7` G C( -Cc »:. � <br /> ' � ,�A <br /> �,� <br /> � �� V♦ <br /> 1 O <br /> ,_ a <br /> , �-_ <br /> � <br /> � ,�'� � ACKNOWLEDGEMENT OF CONDITIONS <br /> � <br /> Thc untlersic�ned owner/applicanl hereby ag�ees lo hold antl save ha�m- <br /> — less the CAy ol Everett Irom any and all claims for tlamages, cosls. <br /> ' �' , eapen5es, or cause5 0� ac�ion Iha� may anse Gecause o� inslallation <br /> �..� - y _ and mamtenance ol lhe improvement o�other ri9hFOFway use herMo <br /> ��� � `- ' -7 applied lor and further agrees to remove same upon notice irom Ihe <br /> ''. Date <br /> Approve�lo � ns ct' City and to replace pubhc properry damaged ihereby. <br /> • j � , . > <br /> ' / � /, ' f <br /> .�-� � "�y <br /> Dale ' ' Dale <br /> FINAL INS TI Si9nature Apo��canl <br /> npprcved as Consiructed <br /> WOR UTHORIZ[D BY THIS PERMIT MUST BE STARTED WITH <br /> � PUBUCWORKSDEPARTMENT 180 DAVS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> 3200 Cedar Stree� BE DILIGENTLY PURSUED TO COMPLETION.7HIS PERMIT A1AY BE <br /> � Everelt,WA 9020� CANC[LLED BY TNE CITY UPON ANY S70PPAGE OF WORK ON THIS <br /> Phonc 259�Bt310 PROJEC7 OVER 90 DAYS DUPATIOIJ <br /> �—__ <br />