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;..: <br />Date <br />� <br />APPIIcetion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Owner <br />Applicant <br />Plan Ch�ck No� <br />1►pplicat.Dat�: <br />Job 71ddr�t�� <br />Own�r� <br />T�n�nt= <br />Propo�W U��t <br />D��c. of Norks <br />RE140DEL/11DDN <br />C 46264 SSPA <br />11 21 93 <br />24 � I6HL11ND AV6 <br />ICITERiE�NN JR[lRY 4 111iITA <br />SIN6LE 111MILY RBSID8NC8 <br />– i2RE D71!lA6S <br />OFlICE SET JOH SRT <br />, D��chbe Proposed Work _ �PROVBD FOR PBRMITt D71TE BY <br />. _/_/_ <br />Pro�eet Addnas (N known) <br />�+ 1 �e��Wa�«.�,,. <br />ewu o.n• — <br />waro wonu F« <br />TOIN Fn � <br />lM �opl FM PNO : <br />B�I�ne� Du� i <br />{p Phone <br />ip Phone <br />Atl�ch four (4) coplee of plans for proposed work • Draw to ecaie and �o�e � Centerline ol aheetGble: <br />� �pp°� ����� • I�dicete North <br />• Outlin� and dlmemlons of �II ezistinq and � Show enY Propoaed qradinp chanpea <br />proppsed stn+eturos on ths lot � ghow mPesurementa <br />• Existlnp nnd proposed utllitiee <br />, . , i PERMIT CONDITIONB <br />.. I 1. IUI plls lor IoW�etlo� ah�ll ba m�de 24 hn. in �dv�ncs • Phone 26P8870. <br />2 NI woNc �II be psAormed �n �o�d�^« wIM thb psrmlt and curront City of Evsrotl Dssipn �nd Constnwtlo^ <br />8tuM�rds �nd 9p�clflcallo�a <br />3. Call loc�tlon UnNryro�nd Ssrvics �8 hra bsforo You dlp. TOLL FREE NUMSER 1-800�42455SS. <br />�UBLIC WORKS PERMIT <br />�fOT HEOUIRE� <br />iV <br />�ATE_ 2 / Zi_ <br />Approved for Construclfon Date <br />FINAL INSPECTION Dete <br />qpproved �s Conatructed <br />�PUBLIC WORKS DEPARTMENT <br />3200 Cedu Street <br />EverotR WA BB201 <br />Phone: 2S9�BB7o <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />H <br />� <br />� <br />� <br />O <br />� <br />� <br />O <br />a <br />The underslgned ownedapp��cant hereby eproes to hold and save harm- <br />less the Cily of Everatl lrom any end all claima for demaqea costa, <br />expenees, or ceuaes of action that may arise becauee af inatallatfon <br />end meintenence of lhe imD�ovement or other riqhPof•w�Y uae hereto <br />applied lor and fuAher aqraea to dameeed thereby.n ��t�ce trom the <br />City and to replace public propsrty 4 <br />! Sipnature ol Applicant Dale <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />1B0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLET�ON. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAOE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />