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Date�� 1 �I I��C� � Pu�IIc Wo�ka Parmit• <br /> aino.oeo�.• <br /> Application For <br /> PUSLIC WORKS PERMIT PubTotaFeoFoe $ <br /> Loss AOPI.Fea PaiC g <br /> BalencoDue $ <br /> Print or Type Only <br /> �a�,� � � ��2�-��vCx�� C,I� l���� c_ �D�v� ��► i r� <br /> Owner Mading Address Ciry� Zip � Phone <br /> -7FC..���J2�.,'"���1 0 <br /> ���� � � <br /> Mailing Address City Zip Phone � <br /> APPlicant �.T. <br /> l� 1 � I/�J�l� �( I��LY�CJ�'' `��/��Q� �l�('�� -�-1 '�il <br /> Describe ProposeA Work l- <br /> ... ---� <br /> �n x <br /> 0 <br /> m <br /> W mo <br /> -r c <br /> Prolecl Address(i( known) <br /> ��-� � � �lL�/-�i�� !�`�� � il'%,.i Z�.h � � m <br /> x -Zi <br /> Attach four i4) copies ol plans for proposed work- Draw to scale and note the following as applicable: � r^ <br /> • Properry Lines • Centerline of street � � _ <br /> • Indicate North e <br /> • Oulline and dimensions of all existing and � _ <br /> proposed structures on the lol • Show any proposed grading ch�nges ,., <br /> • Existing and proposed utilities • Show measuremenis M -a y <br /> W ` <br /> � <br /> o � <br /> DO NOT WRITE BELOW THIS LINE O 'n n <br /> � m <br /> PERMIT CONDITIONS = <br /> m �-. <br /> 1. All calls for inspection shall be made 24 hra in advance•phone 259-881 5. en <br /> 2. All work shall be pertormed in accordance with this permit and current City ot Everett Design and Construction o r <br /> Standards and Specificationa � m <br /> Z c v� <br /> 3. Call Location Underground Service 48 hrs.befora you dig.TOLL FREE NUMBER 1-800•424•5555. m N <br /> � � /Z- /Z - QJs %� rt� � m <br /> � P.-�-�, t �� ��� ,� f � u,-�� p � <br /> � <br /> ,z - �� -8s F.�. z <br /> � � <br /> � <br /> O N <br /> Z <br /> 0 <br /> a ~ <br /> � <br /> m <br /> ACI<NOWLEDGEMENT OF CONDITIONS <br /> The undersigned ownedapplicant hereby agrees to ho�d and save harm• <br /> less the Cily ot Everett irom any and all claims lor damages, costs, <br /> expenses, or causes of aclion that may arise because of installation <br /> , 1 , f� _�� and maintenance of the improvement or other right-ohway use herelo <br /> � applied lor and Wrtlier agrees to remove same upon notice 1rom thc <br /> Approved or onslr�cti � Date City and to replace public properry damaged thereby. <br /> .�A�:�- o?/% -�,L . �� I - I L - G � <br /> NAL INSPECTION Date � <br /> Approved as Constructed <br /> ignalure o�Applicant Date <br /> �WOHK AUTH I D BY THIS PE MIT UST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT �gp DAYS OF `TE PF:RMIT IS I D AND (HERE�FTER IS TO <br /> � 3200 Cedar Slreel BE DILIGEN7 PURSUED 70 CO LETION.THIS PERMIT MAV BE <br /> Everetl,WA 98201 CANCELLED Y HE CITY UPON STOPPAGE OF WORK ON THIS <br /> Phone: 259��815 PROJECT ER DAYS DURAT N. <br /> cg>:a <br />