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� � � <br /> � � x <br /> C H ' <br /> � H � . <br /> H � H Date��(j <br /> Pum,c wo�ws vc„n,�. _ <br /> � y � Applica�ion For o�oa o�oi..__Q(�'/� <br /> y�/! y�H�—}1 PUBLIC V4�'ORKS PERMIT °�°;aWFe�`�° 5 <br /> l•1 O L•l Lrss ApPI.Fae Pm�1 S <br /> � n Print or Type Only �.��,���.�o�� 5 <br /> H �g <br /> �� � <br /> M <br /> � y -�-i�c��f���u �.��/�7��i�o��r �VP/P/� 9.�ZOI �.sa-aaG� <br /> H y wner Madmg Adtlress City Zip Phone <br /> � <br /> otyw SGMQ <br /> � �" � Applican� Mailing Atldress Ci�y Zip Phone <br /> y 0 � Describe Proposed Work �1�1Sr1111_C/N�_�C �����(/�j/� '�, <br /> V <br /> Project Address�il known) ��� 7 � f�i�.+�iN�/Q �LLL � <br /> Attach four(4)copies oi plans for proposed work- Draw to scale and note the following as applicable: � � <br /> • Property Lines s L'enterline of street i <br /> • Outline antl dimensions ol all existing antl • Indicale North <br /> proposed slructures on the lot • Show any proposed 9rading changes I <br /> i ExistC�g and proposed utilities • Shrnv measuremen(s � i <br /> DO NOT WRITE BELOW THIS LINE �\ � <br /> I '�1 PERMITCONDITIONS <br /> `/ I <br /> 1.All calls tor inspection shall be made 24 hrs.in advance-phone 259•8810. � . <br /> � ' 2.All work shall be pedormed in accordance with this permit and current City of Everett Design and Construr,tion I <br /> � Standards and Specifications. i <br /> 3.Call Location Underg�ound Service 48 hrs.before you dlg.TOLL FREE NUMBER 1-800•424-5555. � ;, <br /> ' 1 i <br /> 1_I � ! <br /> 1 ' �T L l L I�tl�-�S �C�.M(1 l�1�-�l�Q� � i I <br /> ��^-"C.��� r^ <br /> �' �/ <br /> �f ���.� O <br /> _I - a <br /> _ <br /> ►_ <br /> �' <br /> �CKNOWLEDGEMENT OF CONDITIONS i <br /> The undersic�ned owner/applicant hereby ayrees to holtl and save harm- <br /> � less lhe City o1 Everelt Irom any and all claims lor damac�es, costs, <br /> �� expenses. or causes of action that may arise because of installati0n <br /> , ar.d mairtenance of the improvement or other righboFway use hereto <br /> applied lor and lurther agrees to remove same upon notice Irom ihe <br /> Approved lor Construction Date City and to replace public property dama�jed thereby. <br /> FINALINSPECTION Dare i <br /> APproved as Consiructed Si�nature of Applicant Date <br /> evcre[t PUBLIC WORKSDEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUST BE STAhTED WITHIN � <br /> � 3200CedarSireel 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everelt,WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY B[ <br /> Phone:259�8810 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS i <br /> PROJECT OVER 90 DAYS DURATION. <br />