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Date � � �y � <br /> PupbC WOrFs P¢rmil s ___1��� <br /> Application For amg oeai.. <br /> PUBLIC WORKS PERMIT PUbTp�aFeeFee s <br /> Lesa pppL Fee PaiO 5 <br /> Print or Type Only ez�a��eo�� s NG Cf/q!'�-E <br /> �oB �h'i.cl 7/0� (Ju�ri/.t.e,�V2�c�� �C� <br /> Owner Maihng Addre s <br /> C�ty Z�p Phone <br /> �� - ,es _ z�8as ��`�.�u� �C,uo,or,3 9�Zu 77s-9�su <br /> Applicant Mailing Address <br /> n ���� Z'P Phone <br /> Describe Proposed Work O+ �{J(. /"[/(/L ����/�U� /��_. � <br /> � /�C/I/ �iQfG,//.SS/ .(J <br /> % � ti.� ��y- _�l�1vY �7/��T�Li � /if/ S� rrli OiF <br /> � � .� <br /> Project Address(il known) � (�r/„��,r � <br /> �ri__� ,z ,� H <br /> Attach four(4) copies ol plans lor proposed work- Draw lo scale and note Ihe lo�lowing as applicable; $EE p/�7 <br /> i Property Lines �✓�,�c�Ci /�y�j(( � <br /> • Outline and dimensions of all existing and • Centerline ol slree� /J/��5 � <br /> • Indicale North T �" <br /> proposetl slructlres on ihe lot • Show an <br /> • Existing and proposed utilities Y Vroposed grading changes <br /> • Show measuremenls <br /> DO NOT WRITE BELOW THIS Line � <br /> PERMI7 CONDITIONS O <br /> 1.All calls lor inspeclion s'�all be made 24 hrs.in advance-phone 259•8810. <br /> ?_.All work shall be peAormed in accordance with ihis permi�and currant City of Everetl�esign and Cons�ruclion � <br /> Stand2rds and Specilications. <br /> 3.Call Location Undergrountl Service 48 hrs,before you tlig.TOLL FREE NUMBER 1-800-424-5555. <br /> /, r � <br /> Ci�y Sf��c�J 2rc � 6e ��Py- Clc�. ,, << 7� ��lC � <br /> � f�e <br /> — ���'�� U/J 4f ��nC�O�' �-�� r� ur C.c/�le� , :Y/%S�c�J <br /> :�. �o� l•E �7` z.,� 1� <br /> l l��.� s, a��,, n� �y. <br /> �. ��l-+u vi����CJ�r - � <br /> S�c�/ ( KM /^or/��.J .f.�ns i�' � �o s��y O <br /> �:.c.��. <br /> 7 /!y� �iro k .. / L <br /> � �i� QrG�tM�iq��� S/OL[✓n [ �c. ,.$�4�� /JrC � <br /> ��,��J�n <[ ��, ✓ <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> ---'-� __ Thc untlersiqned oevner/applicant hereby agrees to hold and savr harnr <br /> less ihe Cdy ot Everett trom any and all claims lor dainayes. costs. <br /> ezpenses. or causes ol action that may arise because of installation <br /> (I� �� � y� and maintenance ol �he improvement or other right�ol-way use hereto <br /> Approvedlor Conslrudio Date appiied lor antl further agrees to remove same upon nolice hom �he <br /> /� � City an re lace public propeny damaged thereby. <br /> i / <br /> ! / �i� /J <br /> � . _ / ,/�� <br /> 4'INAL W �P CTION � �'"� �_ � �� J_ � G <br /> Approved a;Constructed Si gnature of A p p l i c a M `�i7Ge�-t•C.�✓ �U�'�J/7� _ <br /> � � Da�^ <br /> /,1�� PUBLIC WORKS DE�ARTMENT WORK AUTHORIZED BV THIS PERMII iviUST OE STARTED WITHIN <br /> �� 3200 Cetlar Sireet 1f30 DAYS OF DATF PERMtT IS ISSUED AND THEREAFTER IS TO <br /> Everett,bVA 98207 BE DILIGENTLY PUFSUED TG COMPLETION. THIS PERMI? MAY B[ <br /> Fhone:259�BN7U CANCELLED BY THE CITY UPc)N ANY cTOPPAG[OP WORK ON THIS <br /> PRO!ECT C7Ef7 90 ��YS D'Jf-'ATION. <br />