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,�. �- <br /> . <br /> C::ieS S � � �. num�c wor�.s rr�mn. — - � C. (;. <br /> ' / BItlB�OaO��� <br /> Application For <br /> � t��1 �LdC !il//ORKS PERIVIIT �'�� t �r PuhlltWo�ksFae _ <br /> � � .��r� ! ro�a�Foo $— <br /> %j Less AOGI.Feo Pald S—�— <br /> ^� BalancoUuc �' " � <br /> Print :;' fy�p�. :�nly — <br /> _�,4�A.l,rr�, ��SY�c_ 11L� IItIR�����0 3lyr-rt.� 9&' 11�� . <br /> Cwner Maf�ngAddre.ss Cily Zip Phone <br /> �Arzc:�{., n�;.� �cxfi. -,r..o.s. �21���1�nt; loZ_�i—��' 'C���?- lZ-��Y�-- <br /> � Pda� .n9 Address City Zi� Phonr. <br /> Apnlic.snt <br /> C•�scrite Proposed Work �'�r'^fd�1 �� �"�'—`�-� �C'- _— <br /> -- OC� � <br /> Prolec'Address�it known) —�c,�=�s.lr.. J�'�-O � L C."`� �.A"i-�-`�+ `� � <br /> 7 <br /> Attach four i4)copies of plans for proposed work- Draw to scale e.nd nole the tollowinq as applic�bie: i� <br /> � Property Lines • Centerline of slreet �i <br /> • Outline and dimensions of all exisling and • Indicatc North <br /> proposed structures on ihe Iot • Show any proposed gradinp changes <br /> • Existing and proposed utililies O Show measurements /M <br /> m W <br /> �� DO NOT N'fiITE 13ELOW THIS LINE <br /> PERMIT CONDITIONS � <br /> t. All calls(or inspection sha!I be made 24 hrs. in advance- piione 259-881 5. � <br /> 2. All wor4 shall be pertormed in acco�dance with�his permil and current City ot Eoeretl Desigu and Construction <br /> Sl�ndards and Specilica�ions. <br /> 3. Call Location Underground Service 48 hrs. belore you di�.TOLL FREE NUM6ER 1•f�0•424•5555. � <br /> -4, /�..1-r ��,r� ����� � -//-6 S � <br /> 5� �i ,� � ��.�r�r� �r �� y� ✓a c i�/ c��� j � <br /> / � <br /> � <br /> �. <br /> - <br /> ACICNON'LEDGEP.tENT OF CONDITIO�:"' <br /> 7ho und�:rsignod owner/epplicant hereby agrees to holtl antl save harm- <br /> — �-- less the City of Everett from any and all claims for damages, costs, <br /> /� � exp�nses, or causes ot action that may arise because ot installation <br /> � /� �� �_ �� �1--^ and maintenance of the improvement or other right-ohway use hereN <br /> �"'f E�L"� E —�" aPPlied for and further a9rees to remove same uPon nolice irom the <br /> pproved tor Co struction Dale City and lo replace public properly damaged thereby. <br /> ��, - � ' �-- l.�1t.� .._ � r� �/ � <br /> FINAL INSPECTION Dale - - � � Date <br /> Approved,�s Consiructe Signature ot Ap lica t <br /> WORK AUTH 12E 8Y TF�IS PERMIT MUST BE STARTED WITHIN <br /> everelt I PUBLIC WORKS DEPARTMENT 780 DAYS OF DATE PEF.IOIIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Ccd•ar Street BE DILIGENTLY PURSUED TO COMPLETIOfJ.THIS FERMIT MAY BE <br /> Everett,WA 98201 CANCELLED BY THE GITY UPON ANY ST�PPAGE OF WORK ON THIS <br /> Phone: 259�8815 pROJECT OVER 90 DAYS DURATION. <br />