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�� <br /> H <br /> b / <br /> IC � M . /Q , .. rwJ.cKaiksvmmn. .1 <br /> y Date� �i'i �,77/,3? <br /> r � � Appl�ca�,.n For mea oco�-•��,----�-- <br /> � y " PUBLIC WORKS PERMIT PuM1iicWorx�Fac <br /> � .o�a�Fao s <br /> O itl O Less Aoo�Feo�am 5 <br /> � N � BalancoDua S �C . <br /> a � Print or Type Only <br /> �2 �" � ^^ -' /�daNd, G�� ' d �i9 l�,rl�e�ailn� — <br /> 5 y � ner Mailmg Adtlress C ty 2iP L N �6',L?honc <br /> n� � 3s 3 z3 3/ <br /> F y y <br /> � dl i , ���Ir1a��s �s� ;l ?�,F,;���r �� �– ininrf� Z�__/t_�9�F�1z� <br /> � � N ailing Address C�ty Phonc <br /> � � � Applitant <br /> � y tlPvinn�0� � � ���-'-r—��/�.�!�� <br /> N <br /> Describr. Pr000setl Work <br /> � <br /> ProjectAddresslifknownl ���.� ��^ �en. 0 -- � <br /> � <br /> Attoch lour I�i�copies ol plans br proposed work- Draw to scale and note the followin9 as appliwble: � <br /> • Property Lines • Centedine of street <br /> • Outline and dimensions ol all exisling and • InAicate North <br /> proposed siructures on the lot • Show any proposed grading chan9es <br /> i Existiny and proposed utilities • Show measurements M <br /> W <br /> i� �\ DO NOT WRITE BEIOW THIS LWE o <br /> �� PERMIT CONDITIONS � <br /> � � 1.All calls lor inspection sh.II be made 24 hrs.in advance-phone 259•8810. <br /> 2.All work shall be peAormed in accordance with this permit and current Ciry o�C-veretl Design and Construction <br /> . �� StandardsandSpecifications. <br /> �_� 3.Call Location Underground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> QI�� <br /> �-- , � - i `� • I <br /> ., <br /> � �� ��1 t�r. !:��,�� ���-�.,�cc�� ./Jc7`�,�;��_�;. ., ;(? L <br /> �1�� N � <br /> j.1'� r,: i�: - �� o �I <br /> a �� <br /> 4 Iw�� <br /> I 1 � <br /> � k <br /> — ACKNOWLEDGEMENT OF CONDITIONS I 'J <br /> � <br /> � ' The undersi9ned owner/applicant hercUy agrees lo hold and save h2rm� , <br /> �� less lhe City ol Everetl irom any and all claims for damages, costs, <br /> eapenses, or causes of action iha� may arise because ol installalion <br /> and maintenance of the improvemenl or other ric�ht-ol�way use hereto <br /> applied lor and further agrees to remove same upon notice Irom the <br /> Approved lor Conslruction Date City and to replace public property dama9ed thereby. <br /> FINAL INSPECTION ��1e Datr. <br /> Approved as Construcled Signature of Applicant <br /> � WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> /r��./ PUBI.IC WORKS DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200Cedar5lroet �E DILIGENTLY PUFSUED TO COMPLETION.THIS PERM1IIT MAY BE <br /> Everetl,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:25�J�9810 pROJE-CT OVER 90 DAYS DURATION. <br />