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„ . . ... . . _-. . . ,_ .1 1� � v � �_• Nun.lc•t
<br /> • � , „",; � . Ut7t.: �L ��� .
<br /> � ' . ., , A.luster
<br /> � .. �..�,,.:"'ii,� •
<br /> Su:us:
<br /> ;•�i.r�n^iit�n C�nstr��cii-n G�. , Inc.
<br /> Pleax take noticq thai ruit ru �ame �
<br /> p.�, � 7y$ (10^8 Frna3uny) � Ee�i•ett� 'h'� 932(?5
<br /> Who now resides al � � i�� Resiocnce oy Strmt, Number a�d �ty.or i i
<br /> Rural by P•O. Box-Route Number-Nearest Town.) i
<br /> z59 5191 � �d who for six mmths prior to accrual 01 claim or date o! �
<br /> Telephme Num�er. ' ”' �
<br /> accident has resided at 9 ^• �'`X 7�a �1�� �'���':�`'r'•� , "ti ^`tt "� pD�
<br /> (Give Residence u� same manner as anove.)
<br /> C:aims darr.ages o: a�d from the City of Everett in the Sl1T•OS S 69�•�� Pl�s arising ou; of the folloving .
<br /> s, Tax �f 35.70, lc•tal 735.59
<br /> Cir[ums:anCes:
<br /> . Fioceived cnntrect fr..�u City �f �:reit (si�ned �ept. 12� 1977)
<br /> - -----------
<br /> ---------------------------------------------- •
<br /> Explain w•nat hap'xned in a�r•unt .,f 2,174•�0 tr, dem�lish & clear building lncnted at
<br /> � and give t1�e foilowmg � � -------------------------------------------'
<br /> ------------------------'
<br /> intormacim: t) The 2�i.c E. Grand� �erett� Lki. t,� �ttain Cit Pe;mit �a is�..'�cAc 10�26�7?
<br /> date, time and place the
<br /> ---- / /7 -------------------h--------
<br /> injury or damage oo- -----------'
<br /> ------------------ -----------
<br /> c�r.�e; z) riow tn� � mnved nu: eqp. g lab�+r in ll 1 . 7� tn dem�lish. U�r,n arrival
<br /> accident occurred - ---------------------------------------------
<br /> describing City tiefects.
<br /> �u: creas ±'�tu�3 the h�use �!ss �ccu�ied & had t� ab,rt v�rk.
<br /> causing 'u+jury or Eamage __`_
<br /> �.. and all acts of City neg- ---'-----'-------"-'-----
<br /> -----"-------'---------'------'-'------
<br /> ligrnce claimed; a�d 3) hh e_11od y�ur Clty �^ot (�b F.,ye�) nII 11/1�'77 e373Sing �S
<br /> State the nan�e(s1 of any "------'-------------------'--------
<br /> - - - '------------'---'---
<br /> p��so:,(s) who wimes�-d '-c�,diiinns ,�',• f�lloaed up uith speed r,.ea� t;, his ..f±'ico 11�1�77.
<br /> the injury or Lamage. (tl
<br /> more space is neeLed, ----
<br /> ----'------'-----
<br /> --------------------------------
<br /> attaeh a xpa;ate sheet.) � '
<br /> ---- A;tlr. IRt�r
<br /> ----�---------------------------
<br /> --------------------------------------- -
<br /> List i�ems of Ezmage City pe.nit � 1(?.7D .
<br /> claimcd-itemize all es- � -'---'--'---
<br /> -----'---'-----
<br /> -------a'}, ----'-----'--'--'-----'---'---
<br /> penxe and losxs. --""-' �
<br /> At:acA copies of all perf�:rancs brnd � 70
<br /> estimates, bills, or ' � -"-----"---�
<br /> ------'--"------------'---'--------"---------'--'-'----------'
<br /> charges inc�rred� as a y ,
<br /> resul:of C�e intiCe�: and _ 1•1n7B�in B�p�� ----'--------'---'-- - .
<br /> inllcete Ltie items - C:Y'.i6-&-bi'tY`k---------�@:'f0------9tY7:JC---------
<br /> d'en-o•d or injured tor --
<br /> ��a_ �
<br /> which you have r.ot yet' _ 13�.OQ---- lfi(�cOQ---------'-'------------------
<br /> ---'----'----------------------
<br /> -- ' -
<br /> kien Dilird or c•`.eroec� if � - -
<br /> b,y. ;;Lr 133.00 � .'
<br /> ---Iah:----------160:50--------_;------------------------�----------------
<br /> Iab t�:es - .. I _. . y�,.�r'� --�`=-----------------
<br /> _"'
<br /> _ _____L_p..�.V=_m7Y.'_� /o- .
<br /> I (�s2;;�--------Sb.�O '
<br /> � f'fS. € Pr., ��.�0 —p v"�-iC.v.� �_F'-Z'--------------------------------
<br /> ---------- �-----09°.99
<br /> � . • --------
<br /> , S tax ----------------------
<br /> ------ ---------------------
<br /> Accuztely describe i�-
<br /> -------- 'T35:h9�
<br /> jurics or damage. (I1 � ------"--------
<br /> mcre space is reeEed� ---------"--'-'--'---'-'-"-------'--------------'---- .
<br /> a;;¢ch 2 xpzraie s`�eeL)
<br /> ------'---'--'---"----'----'-----"'-----'---------------
<br /> ----'--------"----'--------------"---'------------------
<br /> S7AT�OF \�i.Sfi1�Gi0\l. � _r,., _ , .- . .
<br /> 51 . . �. . w � . r -tnf! .
<br /> COUNTY CF S�O:iO:51SH) � � � � � . �
<br /> 1
<br /> �� C..". Stet18T _, bcm6 fint duty s•+�om,..de;.nse.a��vy-t5at I. .. . . _ ..
<br /> • � ----��pri-n�ame
<br /> am the c;a:mant abovc descriSed; that 1 tsvc read t1,e a�n��c daim� :-�ow �:�e cmtents tt,creof �nd belie��e the ���e .
<br /> to:.e t:ue. . � � , (// •/
<br /> � � �� /��� '-�/'—
<br /> - ^\ to bcforc me . . �f'- �
<br /> SUR��i�li)cD a�d 5 �n• � ICITIIfal1�S�bnJlVl�l
<br /> ;��s.t�r��F�. ot��, re7Y• • — .� � -
<br /> �J(,�.t 7•�. C�.��r".�✓ . �'.�. � . -�
<br /> �_". �n:a�7o t � tale � ct.�� .( �!.j., I'1 • •nl
<br /> • .�JTHIiv UMLIG (f 1•.�•^ Prn�1 Rrvrr� . .
<br /> , ..t v.. �. � . .r: ..t �J:.`i.,:�a�.�t � .
<br /> . ' ..���.'�
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