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� <br /> PuClic Wo�ke P mil� ✓ _ �'�G <br /> �8t6.�� <br /> � / Bldp OBPI.• <br /> Applicetion For _ <br /> PUBLIC WORKS PERMIT PubiicWoiksfee <br /> ro�.�Fao s— <br /> � Lxas nout Fea Peie S y � <br /> BalanceDue S 2�/'' p� <br /> Print or Type Only <br /> daa - „��o <br /> ivi�iu.J O� .,� C�e ��i- 0290/ LJ�a7c�W A�� �P��le `T�/� <br /> �W�ef Mailing Address Ciry 2iP Phone <br /> z <br /> y.!� �cfiwi�� .� ,f 9770 � <br /> d33� y!?ar� ��'T. e/%r�ue_�� �r �' <br /> "f Mailin Address Ciry Zip Phone � <br /> Applicent 9 m <br /> Describe Proposed Work [,�� � ' �^ ��`e\� � � <br /> .. <br /> � ` �, �� <br /> !'� l�,JYf— .-� --i <br /> N S <br /> m <br /> W = u <br /> m o <br /> t-> <br /> d � �� <br /> om <br /> Prolect Address(if k�own) ,� z <br /> � m � <br /> Attach four(4)copies of plans for proposed work- Draw to scale and note the following as applicable: � <br /> • Property Lines • Centerline ol street ,p Z <br /> • Outline and dimensions ol ell ezisting and • Indicate North � <br /> • Show any propo=_ed grading chanyes rp- _ <br /> proposed struclures on the lot � Show measurenients M �'`� <br /> • Existing and proposed utilities W --� N <br /> � <br /> T <br /> DO NOT WRITE BELOW THIS LINE O o � <br /> ..Ti <br /> PERMIT CONDITIONS �m <br /> x <br /> 1. All calls for inspection shall be made 24 hrs. in advance• phone 259•$8?5. � m � <br /> 2. All work shell be performed in accordance with this permit and current City of EvereU Ueslgn and Constructinn o r <br /> Standards and Specificetions. � �m <br /> 3. Call Locetion Underground Service 4B hrs.before you dig.TOLL FREE NUMBER 1•800•424•5555. e N <br /> 'm <br /> O � r <br /> 5! To dE �'o.rlS•-•2vG TE;D GE.e Af�.e'GG'�D PIQ�(/s n <br /> � <br /> 1>.4TF0 /—/7— 8_S � -a <br /> n <br /> z <br /> � � <br /> � <br /> O N <br /> z <br /> 0 <br /> a � <br /> � <br /> m <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owneqxpplicant hereby agrees lo hold and save harm- <br /> less the Ciry of Everelt Irorr any and all claims lor damages, costs. <br /> exnenses, or causes ol action ihat may arise because of installation <br /> �// � and maintenance ol the improvemenl or other righFof�way use hereto <br /> � �` �����/f/� applied lor and further agrees lo remove same upon notice irom the <br /> ApProved for Construction , �e Ciry and to replace public progarty damaged thereby. <br /> �✓ / • �'E`.( l%�`� � � /.� j/�7��•� — <br /> FI II S EC710N Date - Date <br /> Approved as Construcled Si ature of A ican� � <br /> WORK AUT RIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 780 DAYS OF DATE PERMIT IS ISSUED AND THEP.EAFTER IS TO <br /> � � 3200 Cedar Sireet �E DILIGENTLY PURSUED TO COMPLETION. TIiIS PERMIT MAY BE . <br /> Everett,WA 98201 CANCELLED BY Tri[CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone: 259-8815 PpOJEGT OVER 90 DAYS DUR�TION. <br /> 1 <br />