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u. __ <br /> � <br /> , <br /> Date_��I �wPubLc WOMs Pe�m^il• <br /> Bia¢Doo�.+ `��� <br /> Application For <br /> PUBLIC WORKS PERMIT PueTolaiieoFce $ <br /> H Less POPL Fee PaIC $ � <br /> � Baiance Due $ <br /> n <br /> �y r3 Prinl or Type Only <br /> C�H <br /> ?H Cn 1 <br /> yz r�i _�.u� `'- -� L A�F — <br /> K n Owner MaJing Address City Zip Phone <br /> H?1 <br /> "�,� H'i1 <br /> V1 H Z�p Phone <br /> f3O� Applican� tdailingAddress City <br /> x <br /> N t7 ,, _I ( <br /> OH DescribePreR�sedWork �4d,��T`�M ID .S�n����� �P�iCIL�a <br /> � �g <br /> �. � <br /> � y� � <br /> z <br /> �y F+H � <br /> p y H Project Adtlress(il known) � <br /> o ty ti <br /> Attach four�4�cupies of plan;for proposed work- Dra•.v to scaie and note the loilowing a:.applicabie: � <br /> � C r • Cen�erline olStreCi ♦^ <br /> z H� O ProPertY Lincs <br /> y �N • Omline and dimensiona of all ezisting and • Indiwte No�1h V� <br /> proposetl struclures on iC.e lot • �;�ew any proposed 9�adinp changes <br /> � �"'- �- � • Existing and proposed utllities • Show measurements � <br /> DO NOi WRITF BELOW THISLWE O <br /> PERMIT CONDITIONS <br /> 1.qll calls tor inspection shall be made 24 hr=.in advance�phone 259•8810. �4 <br /> 2.All work shall be pertormed in accordance with this permit and current Ciry ol Everett Design and Construction ♦ <br /> '�� Standards and Specitications. <br /> �.�� 3.Call Localion Under9round Ser.ice 48 hrs.belore you di�.TOLL FREE NUMBER 1-800•424•5555. � <br /> �� �� , O <br /> +.a.. J� <br /> /-C>�'�-C�.� Gilot�:- f,',:,;>.c-� �'�� �=�t:,-,��� , � <br /> '�a� � I(� N <br /> !'- /_`� � �/ <br /> "_' tn n(tSTING ���_-- a <br /> i'e_ <br /> ACKNOWL[DGEMENT OF CONDITIONS <br /> .� ,�,� Thr,under;igned ownedapnlicant hereby a9rees lo hold and save harm- <br /> �' � — i less the City ol Evere�l Irom any and all claims for damages, costs, <br /> expenses, or causes cf action that may arise because ot installalion <br /> and mainlenance o� tha improvement or other ric�h4o1-way use hereto <br /> applied for anC furiher a9rees to remove same upon notice Irom the <br /> - Approved lor Construction ���0 Ciry and lo replace public property damaged Ihereby. <br /> PINAI INSPGCTION Date Date <br /> Approved as Constructed Sipnalure of Applicant <br /> � PUBLICVJORKSDEPARTMENT WOfiK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> 180 DAYS OF DATE PERMITIS ISSUED AND THEREAFTERIS TO <br /> 32UOCetlarStreet BE DILIGENTLY PUf7SUED TO COMPLETION. THIS PERMIT M�Y BE <br /> Evere�l,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:255�F3810 pqpJE�TOVER�30 DAYS DURATION. <br />