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. <br /> : > <br /> �.� � -:,_ -_ � <br /> 1 Y �� <br /> Pub�¢ND��s Vrrmit� � — <br /> Date� eiao ocnt • ��/� ��m��) <br /> Applica�ion For <br /> � � WORKS PERMIT P�O�mWo�ksFee s <br /> PUBLIC '°'""" <br /> D � LessAoo��feaPa�e S �--�— <br /> � � 6ain�co oue S � <br /> y�� Print or Type Only <br /> 1 y ' � '17L-1101 <br /> W � ���f��c�.► �o i z�s�= �' � i.��U���s� 98m2 <br /> �M C lY Z P Phone <br /> fp pwner ' Mailing AAdross <br /> �Zp <br /> H C Ciry Zip Phone <br /> �F� Applicani Mailing Address <br /> Q oa <br /> • � 1,�w! St w�G� �-A+ra-�'� <br /> �H Describe Proposed Work —� <br /> t"y <br /> � WM <br /> W �O� �'t y"�— E_FJST� /y,�4Ti/F�P L[IA <br /> project Address I�I knownl � <br /> Attach tour(41 coG�as o�plans for p�oposed work-Draw lo scale and note the lollowing as appi��able: � <br /> � • ProPer�Y Lines • Centedine ol street <br /> • Indicate Norlh <br /> •Outline and dimensions ol all eaisting antl � ghow any Proposed g�admg changes <br /> pfopo80d s�fuC�ures c�Ihe IoI � $hOw measuremEnts M <br /> • Existing and VroDosed utilities W <br /> 1 DO NOT WRITE BELOW�iHIS LINE O <br /> C� PERMIT CONDITION: � <br /> 1. AII calls br inspection shall be made 2n hrs.in ativance�nhone 259•881 5. <br /> 2. All work shall be pedormed m accorda�we with Ihis permit and current City ot Everetl Design and�onstruction <br /> � Standards and Specilica0ons. � <br /> I ��� � �.:1�ocation Underground Service 4B hrs.belore you dig.TOLL FREE NUMBER 1•800•424•55 <br /> iF Or1.vEcu� F.e ,—:y�s caT c,�ass�r o vE� ioT 3 �''✓ O <br /> dE .e'�eaQVEv .9.�o h' <br /> E.�SEM�•✓ t�occ�rnF�/r �"�CiT Pudc ic :.cX.�c tS DEoT. <br /> � �_ . CU�y r�'Nc 0 lnJ k� 7irC� ' � , <br /> j �� - _ _� .l �_�,�+ � <br /> T* �� � <br /> Oa�+/E /�/�ST 7.YOSE O <br /> � S i(JC7 C.0 c.9/L.L�lr C �hC���Elci.�!>,c`O cS'.J�o.PT f�9T, � <br /> �i/r,'iiJ� i✓OT.`.[7 <br /> ��. <br /> - ACKNOWLEDGEMENT OF CONDITIONS <br /> ihe unders�9ned odner/applicanl hereby agrees lo hold and save harm� <br /> less the City ol Everett �rom anV and all alaims �or damages, costs. <br /> �..!�// expenses, o� causes ol action ihat may arise because ol installalion <br /> ,r �� s�✓.�J��.� � �L^ �6 and maintenance o e im iovement or other righl�obway use hereto <br /> s <br /> � �� apP��ed tor and lu the re s lo �emove same upon notice Irom t e <br /> qporpved:or Con Iruclion Date Cit and to�c pu f pr Perty tlama9ed ihereby. <br /> J � <br /> ���_ S .�� <br /> � FINAL IYSPECTION � Date Date <br /> Signa�ur N APP�icant <br /> Approved as Consiructed WORK AU7HORIZED BY THIS PERMIT MUST BE STARTE� WITHIN <br /> neverett PUBIIC WORKS DE.PAP7MENT 180 DAYS OF DA1= PERMIT IS ISSUED AND THEREAFTER IS TO <br /> 3200 Cedar Sire;et BE DILIGENTLY PUF75UED TO COMPLETION.THIS PERMIT MAV BE <br /> �V� Everett,W A 98207 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> �V I phone:2�59�8B15 PROJECT OVER 90 DAYS�URATION. <br /> I <br />