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"„vn' W r <br /> % <br /> , �,��� <br /> Date3 ' `14 2-35_Z-y-'_ P�o���vo,,,Pa�m��. <br /> ( BIaO�e01 .�/��/i�s' <br /> Application For <br /> � �� PUBLIC WORKS PERMIT °°°'�°"'°'"„�° _ <br /> Ta�r�.aa s <br /> LaSs AoO��Fea Pa�� S <br /> � � � Nalance Oua $ '2� r` <br /> 9 y y Print or Type Only <br /> 4 � <br /> '� y z �y�s� G'.�au,� �PD.t� �iF8 �u�i�E rr 9 a-�03 3 5�7- s»r <br /> � H� Owner Mailing Address Cdy 2'p Phone <br /> J7 N �,. <br /> x �' <br /> H <br /> � �.Qj. ty Applicant MailingAddress City Zip Phone <br /> OH �y <br /> p� � Describe Proposed Work /�l Sr I�. <br /> t" y� <br /> yy WN <br /> ��� �.g S-1 �Ny�ftrJ l� A�/�' L OT 4 �.. <br /> M Project Address lif knawn� <br /> fa <br /> H N� Attach lour�4)copies o� Plans lor p�oposed work- Draw to scalc antl note Ihe lollowing as applicahl¢ � <br /> � • property Lines • Centedine ol street ,^ <br /> • OWline and dimensiocs ol all existir.g and • Indicate North V/ <br /> Proposed s�rucWres on the lol • Show any proposetl gradmg changes <br /> � s Caisling antl proposed utilities • Sl:ow measuremeNs /�A <br /> �� DO NOT WRITE BELOW THIS LINE O <br /> I � PERMITCONDITIONS <br /> �� 1.All calls lor inspeclion shall Ue made 24 hrs.in udvance•phone 259•8810. � <br /> i 2,All work shall be peAormed in acc:,rdance with this permil and current City of Everett Design and Construction <br /> Standards and Specilications. <br /> 3.Call Localion Underground Servicc 48 hrs.belore you dig.TOLI.FREE NUMBER 1•800•424•5555. � <br /> `�� I <br /> I � -� , f� t-�P�-I CA'+�FT S l-}-��.� I 1�i�Aa-�- "t'�4'f���rj O <br /> '"T�R�r�l�-N l�(�-I+J <br /> � > <br /> � ��� �f�ox Z 'O >c Z�cJ ?��` L_ /��� �"' <br /> � � � <br /> ��_ O <br /> a <br /> � <br /> � ._ � ACKNOWLEOGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to holtl and save harm <br /> less the Ciry of Everett Irom any and all claims lor damoges, costs. <br /> eapenses, or causes of action Ihat may arise because of installation <br /> �`('� Jl/1 �/.,� �/z�/c� antl mainlenance ol Ihe improvemenl or other righPof�way use hereto <br /> ��C�.l �1� l �` applied lor and lurther a�rees to remove eame upon nolice Irom Ihe <br /> Approved lor ConsVuctio� ��e City and to replace public property damaged thereby. <br /> Q�n�`. � �2-�. i -7j �, „ �, 5'%/Fl�. <br /> FINAL�PECTION Date � � .�"'� --��� Oate <br /> - Approved as Constructed Si�(iature ol A�Cant <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everelt PUBLICWORKSDEPARTAIENT 100 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CetlarStreet BE DILIGENTLY PURSUED l0 COMPLETION. THIS PERMIT MAY B[ <br /> EverolL WA 98201 CANCELL[D BY THE CITY UPON ANY STOPPAGE OF WOFK ON THIS <br /> Phone:259-8810 PROJECT OVER 90 DAYS DURATION. <br />