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��,.,r I �.��� Iw' I <br /> 1 i !�: � � �m� y��� , , ��!��if i�'�����I�';�iy '`������ I <br /> � ,,, <br /> i <br /> Date���'LS� . <br /> Pu011c Worka Pe�m11 s �_ '� <br /> Applic�UonFor emaoenc.� __ <br /> t UBLIC lIt�ORK�s PE�MOT ��`�SqG-s �onewnrWFee s = <br /> �� Tot�IFn <br /> Leas ApP�Fee i'eM 'f <br /> Print or Type Uniy B�IanceOu� a� <br /> / es !J ar �a:� IJ R�a�i��<cr r,,e���F G��O/ �j y - <br /> Owner Mailing Address pi� �7 n <br /> Y Z�P Phone <br /> Les �/c�ar dd3� �U /j ac�.�'ve��.f-� 9��G1 �3�1-U(o7(o <br /> Applicant Mailing Address I City Zip Phone <br /> Describe Proposed Work J iJ`� r� ti� �, �L,����r, �'� � �L�/ <br /> Project Atldress(if known) vi � ��, � <br /> Attach four(4)copies of plans for proposed work-Draw lo scale and note the f lo lowing as applica6le: � <br /> w Property L!nes � <br /> • Centedine of straet � <br /> • Outline and limensions of all existing and s Indicate North i <br /> proposed stru.:tures on the lot � O Show any proposed{7red�ng changes ` <br /> • Existing and prcposed utilities • Show measurements <br /> DO NOT Vl91TE BELOW THIS LINE � <br /> PERh11TCONDITIONS � � <br /> i. All�alls for inspection shall be made 24 hrs in advance-pho�e 259•8815. <br /> 2. AI�work shnll be paAo�med in accordance with this permit and current City of Everett Design anC Construction � <br /> Standards and SpeciNcations <br /> 3. Call Location Undergrountl Service 48 hra before you dig.TOLL FREE NUMBER 1•800•424•5555. <br /> � � ��� �a�r��o� � �,� s� �i �/-8.; � <br /> / � <br /> � <br /> V a� <br /> `� � � <br /> � <br /> ACKNOWLEDGEtAENT OF CONDITIONS <br /> The undersigned ownar/applicant hereby:grees to hold and save harm- <br /> less the City of Everett from any antl all clai.ns lor tlamages, costs, <br /> ; expenses, or causes of acticn that mey ariso hecause of installation <br /> �i� �.Z��� and maintenance ot Ihe improvement or o;her ri9ht•of•way use hereto <br /> pprovetl lor Construction applied lor and further agrees to removo same upon notice Irom Iho <br /> Date Cily and to replace public property damaged thereby. <br /> INAL INS ECTI�N IDate '� � (/�'��2�— <br /> pprovetl as Constructed � � nature oi Applicant <br /> Date <br /> everr.tt PUDLIC WORKS DEPARTMENT WORK AUTHOFIZED BY THIS PERMIT MUST BE STARTED N'ITHIN <br /> � 3200 Cedar Strcet 180 DAYS OF DATE PERMIT IS ISSUE� AND THEF,EAFTER IS TO <br /> Everelt WA 90201 BE DILIGENTLY PURSUED TO COMPLE710N. iHIS PERMIT MAY BE <br /> PhOne: 25g•A875 CANCELLE7 Bl'THE CIN UPON ANY STOPPAGE OF�NORK Ot: THIS <br /> - �� � �t�, N: . �� ' ����� � , � <br /> ,,, � <br /> , . <br /> ._,vd� <br /> , . <br /> -- '� 'f-��. ..�. '�.+='.`!�C'w`"—=--�m��]nrfe,ta_—.�.�g.Yr�+w+ .39�'... �',� wild � <br />