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3�(� l;�i <br />Date _._ __ _ <br />i. . 3�• �: %' _ <br />Application For <br />�U�LIC: �"1/ORK!3 PERMIT <br />Print or ?ype OnlS <br />David Fox <br />�, <br />PubL: Woiks Permil s C✓— �i'� G <br />pICl.papLP BrJ�].�]rJ�]5 <br />PubL�. Works Fce <br />To�ul fec § _ <br />Lass AppL Fce Peid Pu <br />� n/1 <br />Balrnr,e Oue � - L'� ��/ / <br />Everett 9820 347-4667 <br />Mailing Address City <br />t�orthland Hemes Inc. 12637 Woodinville Drive <br />Applicant Mailing Address City <br />Construct Single Family Residence <br />Describu Proposed Work <br />Project Address (if known� ������ - �7Q/�.�i��!/.9 /,rl�_�'F <br />Zip Phone <br />Woodinvil].e 98072 488-0585 <br />Zip Phone <br />Aqath four (4) copies ol plans lor U��Posed worK - Draw lo scale and nr,;e iP�r f illowing as �pplicable: <br />• Property Lines <br />• Outline and dimensions ot eJl oxisting antl <br />proposed strucWres on ihe Ict <br />O Existing and proposed u+ili�ies <br />PERPAIT GONUITIONS <br />G Centeriine of street <br />Z Indicate North <br />C Snow any pwposed gradinc� changes <br />• S'�ow measurements <br />THIS:.!Ir,-: <br />1. AI! calls lor inspection shall be made 24 hrs. in advance � phore 259-$81 ��. <br />2. AG work shell be performed in accordance with thi, pemiit antl current CIi�� r.,l �iverc�t Desi9n and Construction <br />Slandards :ind Specitications. <br />3. Call Lccation Undergiound Service 48 hrs. hefore you dig. TOLL FREE NUMBER 1-SOO•424•5Fi55. <br />� � � � I <br />� .L .�l f3-, �-z-- .%-�_-.� /o ;� . <br />tiUProved for Consvoc�ion � D e <br />/ --/-�7�6 <br />FINAL� CTION G Date <br />Approved as Constructed <br />everett PUBUC WORKS DEP�ATMEN7 <br />� 3200 C dar Street <br />Everetl. WA 98207 <br />Phone:259�8815 <br />ACKNOW�[DGEh1ENT OF CONDITIONS <br />The undersigned ownedapplicant hereby ac�rees to hold and save harm- <br />less the City ol Everetl Irom any and all cl2��as for damages, costs, <br />expenses, or causes ot action that may arise because ol installetion <br />anc maiMenance ol ihe improvement or other right-of-way use hereto <br />�,�piied for antl lurther ayrees to remove same upon notice from th� <br />Cityprfd�o replace public property damaged thereby. <br />�� <br />Signalure of Appli��� V Date <br />WORK AUTHORIZED BY THIS PERIvtIT MUST BE ST:ARTED WITHIN <br />180 DAYS OF DATE F[RMIT IS ISSUED AND TH`_�flEAFTER IS TO <br />BE DILIGENTLY PL'RSUED ?O CGMPLETIOiJ. THIS PERMIT MAY BE <br />CANCcLLED BY TH� CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJeCT OVER 90 DAYS DURATICN. <br />z <br />0 <br />� <br />n <br />m <br />.r .. <br />--I 'Ti <br />.. --I <br />vi m <br />0 <br />co <br />mo <br />n <br />-i C <br />O 3 <br />m <br />--i z <br />m� <br />o � <br />n -+ <br />r= <br />.. �. <br />--I � <br />-G ,n <br />�T; a <br />.i m <br />.r_ <br />ri � <br />N <br />,�-> m <br />C N <br />3 � <br />z c� <br />—� r <br />. m <br />D <br />� <br />-� <br />z <br />� <br />z <br />0 <br />_� <br />n <br />m <br />