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f <br />i <br />� ro <br />C� � <br />N <br />0 � � <br />m .. b <br />Vl N <br />� � � <br />p°o f� <br />�da� <br />� <br />N <br />H <br />N <br />00 y <br />� O � <br />Date�7.(1-=1-19� <br />ApPlication For <br />PUBLIC WORKS PERMIT <br />Prinl or Type Only <br />�>�������•.��,���,..�.� /- — — <br />Bie9 OeW � ���((/��_ '_ _ <br />vubbc Worl.s Fee S <br />Tottl Fee <br />tnvsPn.� ��ePa�a $ <br />balrn. �. i,�c 5 <br />������TTNiI�/���a��"����— --- - � <br />Describe ProPosed Work <br />Project Address 0� known) <br />Atlach lour (4) copies of plans fo� P�oposed wo�k - Draw to scaie and note the �ollowing as applicable�. <br />• Cenlerline of st�eet <br />• Properry L�nes • Indicate Norlh <br />• Outline and dimensio�s of all exisling and � Show any propcsed yr.� m9 �hanges <br />proposed strudures on the lot � ghow measurements <br />• Eaisting and proposed ulilitics <br />PERMITCONDITIONS <br />1. All calls for �nspection shall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shall be pedormed in accordance with ihis permit and current City ot Everefl Design and Constmction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. belore you dig. TOLL FRE'c NUMBER 1-800•424-555 . <br />., o /7 _ <br />, , �-,U � . <br />' ���,t CcJczi � !�i?.i,u , �� r c <br />/ /, <br />t�b' <br />Approved lor Construction <br />Date <br />FINAL INSPECTION Dale <br />Approved as Constructed <br />everelt PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Slreel <br />[verett. WA 98201 <br />PhonC' 259�BB10 <br />� --2 / -f n <br />W <br />H <br />� <br />N <br />� <br />O <br />ACKNOWLEDGflM[NT OF CONDITIONS <br />The undersigned owneyaPP�icant he�eby agrees to hold and save harm� <br />less Ihe City ol Everelt irom 2ny and all claims for damages. costs. <br />expenses. or wuses of action Ihat may arise because of installation <br />and mainlenance of Ihe improvument or other ri9h4o1-way use hereto <br />app��ed lor and fur�her agrees to �emove same upon nufice i�om the <br />City and to rcPlace public property damaged Ihe�eby. <br />Date <br />SignaWre ul ApPliwnt <br />BORDA STOFORDATDC- PEfiM1T ISEISSUED AND iHEREA TER ISHTO <br />BE DILIGENTLY PURSUED TO COMPLETION. TI11S PERMIT MAY BE <br />CANCELLED BV THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OV[R 90 DAYS DUAATION. <br />�A� J . <br />