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x�� <br />ra <br />H <br />� H <br />9HV+ <br />CxA <br />Hz� <br />� � <br />H xl <br />oxo <br />'il H '� <br />f0 H <br />lT] 'zJ � <br />H t7 <br />H�g <br />G] � C] <br />�H� <br />z <br />�y t-+ H <br />Q� <br />e] C7 v� <br />��� <br />2 H Vi <br />H O V� <br />� fy �� <br />�� ' <br />._ _ <br />y � , ,_ - <br />�r�.. �,;,.�; <br />Dale � � " 9 /�7 -. <br />Application For <br />FUBLs� �IVORKS PERM�� <br />Print or Type Only <br />�� <br />Address � i/ Ciry <br />Applicant <br />Describe Proposed Work /�� �-��n� <br />Prolect AAdress (il known) <br />Atlach four (4) copies of ptans for proposed work - Draw <br />O f ;operty Lines <br />o Outline and dimensions o� all exis�in9 and <br />proposed struc�uros on ihe lof <br />• Er.isting and proposed u�ilities <br />0 <br />r�r,i�cwo��.sre�mn/.y /���, -�T_ <br />BitlB�eGt• �/� �[� �G/ <br />V�u �Y/orM¢Feo $ <br />,�.a, F�o <br />L�ss Apol Feo PaiA S <br />(3,�iance Due $ <br />Zip Phone <br />9��0 � ��- �0�' <br />Zip Phone <br />scale and nole ihe fullowing as apphcable: <br />• Centerline ot streel <br />• Indicate North <br />• Show any proposed 9radin9 changes <br />• Show measuremenis <br />PERMIT i;ONDITIONS <br />L.111 ce!is tor inspection shall6e made 24 hrs. in ativance- phone 259•8810. <br />2. All work shall be pertormed in accordance with this permit and current City ol Everett Oesign and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. hefore yuu dig. TOLL FREE NUMBER 1•800-424•5555. <br />; ��'i i �G6.� c�/�.� P�>�/1/� �g.�.�.�� <br />� �� ��� <br />� y -/9- 9/ <br />� <br />oll <br />Approved tor Constructian Date <br />FINAL INSPECTION Date <br />nnaroved as Constructed <br />everetl PUBLIC WORKS DEPARTMENT <br />� ;i200 Cedar Sireet <br />Everett, WA 98201 <br />Phcne•: 259�8810 <br />W <br />a <br />0w <br />_ / <br />e <br />ACKNOWLEUGLMLNT OF CONDITIONS <br />The undersigned ownedapplir,anl hereby agrees to hold and save h�rm� <br />less the Ciry ol Everett Irom any and all claims for damac�es, co;is, <br />expenses, or causes ol aclion that may arise because o� installation <br />and maintenance ol ihe improvemen� or olher ri�h4of�way use herelo <br />applied (or and luriher agrecs lo remove same unon notice �rom ihe <br />Ciry and to reDlace public property dama9ed thereby. <br />Si9nalure ol Applicant Da�e <br />NlORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DAIE PER611T IS ISSUED AND THEREAFTEF IS TO <br />6E DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT CVER 90 DAYS DURATION. <br />