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Datc � �.�f �_..��.._�•.-o,..�����,��. 7 <br /> ��:ocm ���ajJ�y�� <br /> Appiicatinn For <br /> PUBLIC WORKS PERMIT '°°;a,e«�`eB s <br /> H Lcaa�oN.Poe P.vu S . <br /> .,y'C C'il n�i,�cn��e 5— _" — _-_' . <br /> ��y y Print or Type Only <br /> ,o�x <br /> ;y� io9aa-SGfNL' <br /> r 3: i �„ � i r .. . �.4! i /�E a�J �'-07� <br /> r a3 I� vo -7nHnSvn � � - - <br /> N z~' Owner Mail��g Atltlress Gty � 2ip Phone <br /> K O <br /> �3:tl <br /> � H'TJ <br /> N~ MailmgAddress City Zip Phone <br /> ApplicaN <br /> � y� J [<� <br /> O H Dc�uibe Proposed Work _�{}��11� L�.Il4(J�P�� P� 1 �"����lG/-bvTM _ <br /> � �� _ _ <br /> n,. �: — <br /> zH� �r y z -- __ <br /> g �H Prcicr.l Atldress lit knownl —!lJ-f-�—��{-' - -- - -- — � I <br /> n C7� <br /> � C: Ntaci��our 14)copies ol plan< lor proposed work-Drew�o SCale and no�e�he�ollowing as apU��ce:,le e <br /> j ��� i Properly Lmes • Cenlrrline of sireet '^ �' <br /> SS y C'1 • Oullina and dimensions ol au e*isLn9 ,mtl • Indm,te North V� <br /> y �� proposed slructures on Ihe lot • Show any proposed y�.,dmg �..i��:�.,•,�.;��c . <br /> • Exi,�in9 antl proposed utddies • SI'.o:v n���ns�.�rnmcnis a�/� <br /> W <br /> DG NOT WRITE BLLOW THIS I.INi Q � <br /> - PERMIT CONDITIONS <br /> 1.All call��for inspection shall be made 24 nrs.in advance-phone 259•8810 � -� <br /> 2.All workshall be peCormed in accordance with Ihis permit and eurrent Ca, .�i '�ven�n U�-�,iqn nntl Go�ictrucnon <br /> Standards and Specilicalions. <br /> '+ �.� 3.Call Location Underground Service 48 hrs.before you d�9 TOLL FREE NUMBER 1•800•424•5555. � i <br /> � ~ � <br /> 1�10 i-� � ��M � ��-c,�, � <br /> � , ,-� � -1-�i�. '�YVI�(c� �����yc � <br /> i <br /> � Na�€ o ����-=p�-��-;a�,�r�=-�=�--�►� � ( <br /> � � � . . - , = Q <br /> -���i��-� i�-d� � �o 'c���—���'f'�T��."� ) <br /> �' -- <br /> � <br /> — c/'�� 1C_'vro <br /> �` . • r�,mvOWLEDGEMENT OF CONDITIONS <br /> The undersignetl owneVapPlicant hereUy agrees to hold and save harm <br /> less the Gty ot Everett Irom any and all claims lor damages, costs. <br /> �zpenses, or causes ol action �hal may arise because ol ins�allation <br /> �" ^� and mainlenan�e ol lhc improvement or other nghbobway use hereto <br /> _— aUP�ietl 1Gr nnd lurthe! aprees to remove same upon noBce hom the <br /> Approaetl tor Conslruclion ���e Qry 2ntl to replace publ�c property tlameged thereUy. <br /> I�I fU�� INSPECiION ���Q <br /> �;np�ov��d as Con;iructea Signature o1 AnPlicaN �a�`' <br /> WORK AUTh�ORIZG� BY THIS PERMIT MUST BE STARTED 11'lil��'; <br /> ,..,,.�,.�� nIE3LICWORKSDEPARTMEN7 180 DAVS OF CATE PERMIT IS ISSUE[� AND THFREAfTER �� �� <br /> i�OCe0ar51reet BE DILIGEM7LV P.:FSUED � �=��'�'��� f LC �I TI115 � E���u� I1:. <br /> L ,rett WA98201 CANCELLE��3Y THE GiY l <br /> �� �,. y5p�F3�ip 1=r,(i.ICCT��l'�I 1 f A",- . <br /> — � <br />