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1�('�H <br />mn� <br />aH <br />A7 .b T. <br />>H� <br />Haa <br />� zH <br />Ky� <br />=7 H "+J <br />y�C <br />xza <br />t� o h <br />pH� <br />H C�? O <br />n � c� <br />H <br />ra+yz <br />Hy <br />nq Cq7 � <br />3 t+7 C <br />Z H C/i <br />H O [/� <br />'� � <br />�ma. � <br />r"" "m <br />�._.-,- � <br />,. 4 <br />i, ' <br />Date <br />Appllcation For <br />PUBLI� WORKS PERMIT' <br />Print or Type Onty <br />� ;.._- <br />Applicant <br />Mailing <br />...: D�.p v --y-_—__._'__ . <br />PuCLCWo�kSPee S ��� <br />.a�r� re< <br />Less AOG�. Fee Paia S '— <br />�alanccoue 5 <br />� '. ' ` ` --- <br />1 �l' <br />���Y ZiP Phone <br />__ __ ------- — <br />- -- -- �:,��.� <br />c� . _�,. <br />De,cribe ProPosed Work i 1 1/�� I �'11 ` �a_l' 1! ___—____.._ ____. _._ __ —. <br />Pro;eet Atldresslif known) �� �t� � � F �`%:_ � �� � � � �, <br />f.!I::ch �our (4) copies of plans for proposed worh - Draw lo scale and note ihe lollowing as applicabla <br />• Property Lines • Centerline ot sVeet <br />a Outline and dimensions o� all existing and • Indicate Nonh <br />n�opused strw;lures on the lot • Show any proposed gradin9 chan9es <br />• Eristiny and prePosoA utilities • Show measurements <br />PERMIT CONDI7iONS <br />t. All calls for inspoction sh, II Ue made 24 hrs. in advance � phone 2$9•881 5. � Dns9n nn� Construc�ion <br />2. FII wo�k shall be performr.d m acmrtlance wilh Ihis permil antl cw�e��t Cit�� �%I cv�:ret <br />Slantlards and Saeci�ications. <br />3. Call Lo:.ation Underground Service 48 hrs. bebre you dig. TOLL FREE NUMBER 1•800•424-5555. <br />�'�j � S �� td�-�.�-� lS / 11 C't j(= j`l/� � t,l%/ -� c,,_ <br />/ � L _ . /�� � � C�E/.c..:. � / S <br />G�(J �(.lTy— /5SU't' !�. �,�/�Ir'' L ��• <br />/ <br />� C�%���J/�� <br />SLC�� � /�j `r, <br />-- .. .. i� � .. ` _�1-��,L � � ' � , "'—t G[. <br />� o � � Is�-�% C ( - , -- <br />� i��= <br />;�opio�ed lor Consiruction Dale <br />�INAL INSPECTION <br />,\�ruoveU as Conslructed <br />�,�.i.��.�� PUBLIC WORKS DEPARTMFNT <br />� 3200 Ceda Sireei <br />1 �re��. V!!' 98201 <br />f I n:�. ,ii15 <br />G <br />' <br />�/ <br />' ;� �Ii.��S.a_.. c'=� L.i/ / . <br />L� � � � �� �— . <br />� ACKNOWLEDGEMENT OF CON�ITIONS <br />The unnerslgned owner/apPlicant hereby agrees to hoid and sav� ��arm� <br />less Ihe City ot Everott Irom any and all claims for tlam�ycs costs, <br />expenses, or causes ol action that may arise because ol inst:ill;ition <br />and mainlenance of Ihe imp�ovement or olher righPof-way usc immto <br />applied for �nd Wrther a9reos to remove same upon nutiae ������ thn <br />City and lo replace public property damaqed thereUy. <br />Dale Dat <br />Si9nalure ol Applicani <br />WOFK AUTHOPIZED BY THIS PERMIT MUST BE STAPTED VJIIHIN <br />180 DAYS OF DATE PERMIT IS ISSU[D AND THGREAFT[R IS 10 <br />BE DILIGENTLY PUI75UED TO G0�.IPLCTION TI�IIS PE17F.1iT F.1n � k7E <br />C�NCELLED BV TIIL CITY UPON i�N'! STOPPAI;[ OP` 'Ofil< Ut: THIS <br />f� -)JI.-('.T n` �.6 ��' f1�.1" (1UR TIC�hI <br />