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�..v.ra <br /> W�� <br /> � <br /> �Hm I <br /> y�� � <br /> ;� �� <br /> �y � 9p izp3/�C <br /> Date 1 9 `� - 3 t�- ��j-`E- r�ori�woikz Po,m��. a 7 (1— <br /> h'3 x� ��T�� I � BIaO.DePt• "___ � <br /> "'� Applica�ion For <br /> t�7 Q � <br /> F y PUBLIC WORKS PERMIT PuOTotaFee`co � <br /> �j � g Lasa ROP<<ee Paitl S— I <br /> �i1� O �7 <br /> Ba�ancn Oue 5�:�� <br /> a y� Print or Type Only <br /> t� � <br /> HH p <br /> hI' ~ �'oec .rifo � 7 f�>r� 1 h'Ckr�3-�i-'� CVP/A� /��•2Qj .3``�'3- 4 -- <br /> ����" Owner � � Maihng Address C ty Z P Ph��n <br /> �'� � 2iP Phone <br /> A� Mailing Addre�s City <br /> G'P- IZu'Z�- IQ:�'Z�� <br /> � / j1 7 �(�-�� -T-r� .�/ <br /> Describe Proposed Work /V�t� I C 1 u!a�P "1�n LU I�7 r P s � � If ( � � �T� .] L7�=q��-�T� <br /> W <br /> projecl Address lii known) . <br /> � _ � � �- <br /> � <br /> Attach tour(4)copies o�P�ans lor proposed work• Draw to scale and nole Ihe lollowing as applicable: � <br /> • Property Lines • Cenledine of sireet <br /> - • Outline and dimensions ol all eristiny and • Indicate Norih <br /> (/ � proposed 5trucWres on Ihe�ol • Show any proposed gratling changes <br /> I C�� • Ezisting and proposed utililies • Show measuremenls � <br /> i � DO NOT WRITE BELOW THIS LINE � <br /> 1 , <br /> �s � PERA!ITCONDITIONS � <br /> � � `= 1.All cells for inspectlon shall be made 24 hrs.in advance-phone 259•8810. <br /> i 2.All work shall be pedormed in accordance wilh ihis permit and wrrent City ol Everelt Design and Conslruction <br /> Standards and Specilications. � <br /> I 3.Call Lowtion Underground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1•S00•424•b555. <br /> 1 r ' O <br /> I�i � <br /> , �_ C� � <br /> _ a, � <br /> ', <br /> _ <br /> �-- <br /> __� <br /> � ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to hold and save harm� <br /> less ihe City ot [veretl Imm any and all claims lor dama9es, cosls. <br /> ezpenses, or causes ol aclion lhat may arise because ol installation � <br /> �0��/��/�/L;.� G/Z�/y� and maintenance ol the improvement or other right�obway use h^reto <br /> Y�( �'�=' applied br and Iu�Iher a�rees to remove same upon nolice Irom tl�,e <br /> ppprove�fo�r Consir t�bn a�e Cily anA to replace public property damaged ihereby. <br /> �-l'�� 2 'Z�-�/ � , = <br /> � '.�9� > ��'�� <br /> FINAL INSPECTION Date . <br /> Approved as Consiructed Signat re ol Ay�� t <br /> WORK AUTFi RIZED BY THIS PERMIT MUST BF <br /> everett PUBLICWORKSDEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AN � <br /> � 3200CedarSiroet BE DILIGENTLY PURSUED TO COh1PLETlO' � <br /> Evercll,WA 98201 CANC[LLED BY TFiE CITY UPON ANY ST' <br /> Phone:259�BB10 Pf70.iECT OVER 90 DAYS DURATION. <br />