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Jate��5'(o P�����wo,�5�,.-rt�„ —. <br /> / Applicatinn For emp.oeo�-� —���J�'--rl—.I— <br /> PUBLIC WORKS PERMIT °�°;o,aFaaF'° s —_. <br /> trssAoo�PoePaiG 5 <br /> Baianc�0un S" <br /> Print or Type C71y <br />' ��'� (S �A �fc� � S�iil'� �l3/� ��OMl1 � != V?/[�/' �•iv� l ��S '� U Y.S('� <br /> T p�e� Mailing Address City Zip Phone <br /> �,'/' �l1 D _ <br /> ^ Appliwnt Mailing Add�ess Cily Zip Phone <br /> i J � <br /> Describe Prouosed Work � � ?�L. ��f,r�n�,r .�'✓/_(�/'._ /J�_(/f i��� 0 . <br /> W <br /> Project Address(il known) '`� � � <br /> Atlach fow(4) copies ol plans br Froposed work• Draw to scale and nole the lollowing as applica6le� � <br /> • Property Lines • Cen�erline ol sireet ♦^ <br /> s Outline and dimensions of all exis�ing and • Indicale North ��/� <br /> proposed struclures on�he lot • Show any proposed yrn7ing changcs <br /> i Existinc�and proposed ulililies • Show measurements �A <br /> fli� <br /> DO NOT WRITE BELOW THIS LlNE � <br /> PERIdIT r,ONDITIONS <br /> t. All calls for inspection shall be made 24 hrs. in advarce- phone 259•881 5. Is� <br /> 2. All work shall be perlormed in accordance with this permit �nd current City of Gveret� Des c�n and Consiructien ♦ <br /> Standards and Specitications. <br /> 3. Call Loca�ien Undcrground Servir.c 49 hrs bclon.;you dig.TOLL FREE NUh1�ER �•H00•424•5555. �+ <br /> �a <br /> � <br /> ?�U,CJ a`./C_ CcJO,c:��; l'�E,c'���/ /'O� ,<�- c,'c;%r'�,C� /0:,2�-�� � <br /> �-�J �' <br /> Vj <br /> �/� <br /> 1.� <br /> � <br /> ACKNOVJLE7GEMENT OF CONDI1lONS <br /> 7 he urdersigned owneriepplicant hFreby agrces to hold an�]savr.harm� <br /> —� Iess ihe City of Everetl irom any and all claims for damages. costs, <br /> expenses, or causes ol action �hat may arise because ol insta�'aPon <br /> and maintenance of �he improvement or other right�of�way usc hr�eto <br /> applied for and further agrees lo remove same upon not�ce Irom the <br /> App�oved lor Gonsiruction �a�e Ciry and to replace public property tlamaqed �hereby. <br /> FINA� INSPECTION Da�e — <br /> Approved as Consiructed SignaWre ol Applicant Oate <br /> WORK AUTHORIZED BY THIS FERMIT MUST BE STARTECI WIIHIN <br /> .:cecel� PUBLIC WORKS L1EPnRTMENT 1g0 DFlVS OF DATE PERMIT IS ISSUED AND THEI7EAF?ER IS TO <br /> � 32C0 CeAar Straet BE DILIGENTLY PURSUED TO CGMPLETION. THIS PERMIT "AAV BE <br /> Everett,WA�JB201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF VJORK ON THIS <br /> Phone: 259-8615 PROJ[CT OVER 90 D�YS DURATION. <br />