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Pu�llc Work�MrmX• <br /> 4� q2� � <br /> i <br /> �8� ' � B�Ap.Dwi.• <br /> Appllcetion For <br /> PUBLIC WOF�KS PERMIT ��OlkWork�Fee , <br /> Totei Fee <br /> Len ApO��FM P�iC s <br /> B�I�na Due S� <br /> Print or Type Only <br /> j��JZ �p����p �fbOB �woac� {��vE l�N.�.,�oro� 9BLD� � - S�8/-CA53 <br /> C��Y Z�p Phone <br /> o�t W�ef �—r MeiMnq Address <br /> N�u�n C�v� �� aox 9s8 �rr 9sZo� Zs�-919 I <br /> City Lp Phone <br /> Applicent Meiling Addresa , <br /> Describe Proposed Work �L� OF <br /> I�s�y FbR C - ,,,_.�,.,...�-..,�.i i�,n���-c <br /> t�JP <br /> ��� ��ASS i A�A �3�"�� <br /> -- W <br /> l `j � � 6�Nn /a✓C.-- � <br /> Project Addresa(it koown) � <br /> Atlech four(4)copiea of pSane for proposed work• Drew to scele and note�Ce�l�erline ot atPeet�ble.: � <br /> • ProperlY Lines • Indicate North <br /> • Outline and dimenniona of ell eziatinp a�d � ghow anY Proposed grading chanBea <br /> proposed atructureb on the lol � Show meaeurements � <br /> • Etieling and proposed utilitiee <br /> . DO NOT WRITE BFL W TMI LINE O <br /> PERMIT CONDITIONS � <br /> 1.All ulls for inopection she0 bs mede 24 hn.in advance•phone 259$810. <br /> 2.All woAc ahell be performed��ece°rdence with lhie permR and current City of Everett Deelpn and Construetlon <br /> Stend�rds end SpecM�ntiona. � <br /> 3.Call Locstlon Underpround SeroMe 4g hn.be�ore you dip.TOLL F11EE NUM6ER 1•800'4245555. <br /> q� InS��� �1�351i�9 k�rr;c�5 z5 ✓ no�l,��s on ��aK O <br /> ' ����--wG� 12-3'`�2 �o bl���- O�F sid�valK. <br /> � <br /> � <br /> , � <br /> a <br /> ACKNOWLEDGEMcNT OF CONDITIONS <br /> The undersignee owner/apPlicant hereby egrees to hold end save harm• <br /> less the City ot Everetl irom any and all claims tor demages, cosls, <br /> expenses, or causes of aclion that may arise b9cause �t useehlereto <br /> /, '/1 � ��,� ���2^y� and mainlenance of the improvement or olher ri ht-obwaY <br /> y��L � applied lor and further agrees to remove seme upon nolice Irom lhe <br /> i Date City and to replace public property damaged thereby. <br /> Approved for Constr lio� <br /> � �';��f S�xi�.'-� /L Z 5 � <br /> �-- pa�e �U Date <br /> FINAL INSPECTION SignaWre of ApP���ant <br /> Approved es Construr,ted WORK AUTHORIZED BY THIS P�RMIT IdUST BE STARTEO WITHIN <br /> � PUBLIC WORKS DEPARTMENT gE DI�LIGENTLY PURSUED TOICOMPLED�ON TH SEPERMIT MAY BE <br /> 3200 Cedar Street I <br /> Everett,WA 9B?01 CANCELLED BY THE C1TY UPON ANY STOPPAGE OF WORK ON THiS <br /> Phone:259-l3810 PROJECT OVER 90 DAYS DURATION. <br />