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<br /> i Date�� � `
<br /> � am�m worFs Permn a , �
<br /> � Application Fr. � 01a9.Dept.s�
<br /> ��T�
<br /> PU�LIC WORKS PERII� IT P�����=W�,�=�Ce — i
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<br /> I Less'ma�.Fee raia 5 .
<br /> � Print or Type Only e,�,,���o�� s=__
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<br /> ! «=-a�T K�i� �a�� ��� / ll��� ��-�.� �.�y����_ '��
<br /> i Owner Maihng Address City ZiF Ph.,ne
<br /> �.,' APPlicant blailmg Address Ciry Zip ��o�-'� '�.
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<br /> I� Deecrlbe Piaposed Work ���.��� �������/� '
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<br /> ' ' � �?_I ik t P NOu.awG � I
<br /> I Project Address lif known)
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<br /> i Attach lour(4! copies of plans lor proposed work- Draw to scale and note the following as applicahle: �� ''
<br /> i • Properry Lines • CeMedine of street � '
<br /> ' • Outline and dimensions o�all existing and • Indicate Nnrth i
<br /> proposed slructures on the lot ! Show any proposed grading changes
<br /> ! • Existing and proposed utilities • Show rneasuremeNs � I,
<br /> � �
<br /> �� DO NOT WRITE BELOW THIS LWE � ;
<br /> i PERMITCONDITIONS %
<br /> ; 1.All calls for inspection shall be made 24 hrs.in advance-phone 259•881 Q � �,
<br /> i _ 2.All work shall be pertormed in accordance with this permit and wrreni City of Everelt Design and Construc[ion
<br /> � Standards and Specifications. ,
<br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800•424•5555. � �
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<br /> li 6• 172uG drt w•eway o-rr��z`o n..+� a,az..w•-1. �,.i �''f�,�7` �
<br /> ' on f/or�Ja��'� . ° �.
<br /> j ACKNOWLEDGEMENT OF CONDITIONS
<br /> , The undersigned m4ner/applicant hereby agrees to holC and�ave harm- ��
<br /> ' less ihe City of Evetetl Irom any and all claims for damages, costs. '
<br /> : / ezpenses, or caus2s ol�action that may arise hecause of installation '
<br /> ' ��' G / �� �� and maintenance of Ihe improv�ment or other righl-ol�way use hereto �
<br /> � applied for and further agrees to remove same upon notice trom the
<br /> . Approve? 7or Consinicti .= Date City and to replace public properry damac�ed thereby.
<br /> , �i( ���� ����O '' f / ql�
<br /> '. f IPd�.L !N,^or.CTION Uate r� � ` iC-/L/1/ ��� /'�U � /V
<br /> , �UProved�s Constructed Signature of Applicant Date
<br /> evcrett PUBLIC WORKS DEPARTMENT WOFK AUTHORIZED B THIS PERMIT MUST BE STARTED V✓ITHIN
<br /> ; � 3200CedarS�reet 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO �,
<br /> Evereit,WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY B[ �
<br /> Phone:259�8810 CANCELL[U BY THE GTY UPON ANY STOPPAGE OF WORK ON THIS
<br /> PROJECT OVER 90 DAY'S DURATION.
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