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L•!�� <br />ay <br />C�H <br />9 H V� <br />H �� <br />K C] <br />H� <br />� H � <br />fA H <br />� O� <br />OH <br />��g <br />4�v Cq� <br />9 H [s1 <br />rHH <br />gy <br />H <br />C� t7 fn <br />� � t=1 <br />7; y rn <br />H C v� <br />Date�3�.�st'�` <br />Application For <br />PIJBLIC WORKS PERMIT <br />Print or Tvpe Onl/ <br />3 <br />Owner <br />Haaress <br />w....; <br />PubM1[ Works Parm�l + <br />elep oeo�� � —P-�'-LPZ-�D- <br />PULbc Worxs Fee <br />rmai vee 5 <br />les5R00� FacP:utl 5 __ <br />oaiancc o�e S <br />�59-�731 <br />�za 3 �sd�-i9.�a <br />Zip Phone <br />Z�P Phone <br />Describe Pronosed Work /��P u1 f inY= An r p �n,c, p— lni.f� /yl�lC�_�( p0�7'- <br />T- <br />Prol'-'ct Atltlress (il known� <br />Attach four (4) copies of plans lor pwposed work - Draw to scale ano note Ihe lollowing as applicoble� <br />• Property Lines • Cenlerline ol street <br />• Outline and dimensions ol all exisimp rmd • Intlicate North <br />proposetl structures on the lot • Show any proposeA y�adin9 changes <br />• Eaisting antl proposetl utihties • Show measuremerls <br />PEflM1T CONDITIONS <br />1. All calis lor insne�'ion shall be made 24 hrs. in advance - phone 259-8810. <br />2. All work shall be ped�rmed in accordance with ihis permit and current City ol Everett Desigi, anA Construc!ion <br />Stantlards and Specilications. <br />3. Call Location Untlerground Service 48 hrs. belore you tli�. TOLL FREE NUMBER 1-$C?•424•5555. <br />���=rti� ��y�-�4 <br />� <br />Approved lor Construction Dale <br />FiNAI. INSPECTION Date <br />Approved as Constructed <br />everetl PUBLIC WORKS DEPARTMENT <br />� 3200CedarStreet <br />Everetl, WA 98201 <br />PhonC 259�F3R10 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />Z <br />O <br />� <br />� <br />O <br />� <br />The undersiqneU owner/applicanl hereby a�rees t.� hold and save harm� <br />less Ihe Clly ol Ev�rett Iron�� any and all claims for tlamages, costs, <br />oxpenses, or causes ol action thal may arise because ol installalion <br />and maintenance of Ihe improvemen! or other ri,;�hFc'>way use herelo <br />applied lor and lurther ac�rees �o remo�..� �.a�ne upon notice irom Ihe <br />City anA fo replace public praper�y tlama9e; �4: �- L•y. <br />Sic�nature ol Applicant � Dale <br />WO�:K nUTHORIZ[D BY THIS PEF:'I7 MUdI BE i>fAR,'ED WITHIN <br />18U :1i:Y:i OF DA"� ^ER;.I!i ij �,;iSl'•�U 4ND THEREAFTE�i IS TO <br />BE DILIGENiLY PURSUEC� TO C(if.i^LFTIU.^J. 1HIS PEHMIT 1.9AY BE <br />CANCELLED BYTHE CITV UPON ANYS�G�i ''��C:i: ')^ WORK ON'HIS <br />PROJECT OVER 90 DAYS DURATION. <br />