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.�.__.. . <br /> __ _ __ ___ - _ <br /> Date 3 5 �� I, � v�ou�wo�ks ae,mn= � <br /> APPlicati0n For eiae.oeo�.s �rl1 / i `U��' <br /> � <br /> PUBLIC WORKS PE�MlT ' � P°°���W°�k=F°a <br /> To�xl Fee g -- <br /> � Less Appt Fen Paid � - <br /> Print or Type Only e��a��o o�� s = <br /> _i � I y ��I� rF•,, ,��c �„ ur�si�, � � `l7d S- 3���1 ��v� /✓� SvGt�ip ;tJ/,� 5a �a0 ' <br /> Owner � Mailing Address City Zip Phone <br /> I <br /> �o vN Q <br /> applicanl �dailing Address Ciry Zip Phone <br /> �' Describe ProPosed Work _ ��(�cin���� ;i1 i�/D U �F� ( �[ � .r- Y(�/�'�� ����� �,-� �1��_ ;' { �U/'�f� <br /> i <br /> i _—' —_ — <br /> I �I <br /> � Project Addreas(il known) G -S — � ✓(�/P ��� < � �� O � <br /> � Atlach iwr(4) copies ot plans lur proposed work- Draw to scale and note ihe following as a plicable: �� <br /> i <br /> � • Property Lines • Centerline of street � <br /> • Outline and dimensions ot all existing and • Indirate North <br /> j proposed s�fuC�urr.s on inc lo� • Show any proposed grading changes <br /> ' • Fxisting and proposed utilities O Shuw measuremenis � <br /> i DO NOT WRITE BELOW THIS LINE <br /> � PERMIT CONDITIONS o <br /> � 1. All calls for inspection shall be made 24 hrs. in advance- phone 259•881 5. � <br /> 2 All work shall be perforried in accordance wilh ihis permit and current Ciry of Everett Design and Consiruction <br /> � Standards and Specilications. <br /> � 3. Call Location Underground Service 48 hrs. before you dig.TOLL FREE NUMBER 1•800-424-5555. � <br /> /v�(� /�G/•'�i'i C G..Jl3!;�S •�r�'i�i i i�� iL��Gj(j/.t c r!� O <br /> � <br /> �s, ��' 3�1� � <br /> 0 <br /> � � <br /> � <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees to liold and save harm� <br /> -- iless the City of Everatt from any and all claims lor damages, cosis, <br /> e..penses. or causes of action that may arise because of installation <br /> and maintenance of the improvement or other righl-ol�way use hereto <br /> --- anP�ied tor and furiher agrees to remove same upon notice Irom the <br /> Approved for Cons�rurtion Date Ci�y and tu renlace putrlic pronerty damaged ihereby. <br /> FlNAL INSPECTION Y DaPa — _ <br /> � Approved as Gonshu.r,ted ' ignatwe:rf Appllcant Date <br /> PUBLIC VJOr?KS DEPAHTMENT INORK AUT�IORIZ.EO BY THIS PERMIT MUST BE STARTED WITHIN <br /> evere[t 180 DAYS O° SJ4TE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> i � 3200 i.eaar SVeet BE �ILIGENTL'/ PURSUED TO COMPLETIGN. THIS PERMIT MAY BE <br /> Ev¢relt.WA 987.01 CANCELI Ep o7'THE CITY UPON ANY STOPPAG[OF WGRK ON THIS <br /> i Phone: 259-8815 PROJE:T OVER 90 DAl'S DURATION. <br /> L. .___ _ _. ..._._.___. .. ._... ___ . _ . .__'. . ._ ._. _. _ __._ _.. .. . . . _. . .. _ . . . _ .. . . . .. <br />