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Date ' I �J_ � ��s <br /> ^�':T!l �� PuLhc Work9 Peemli s <br /> l–•'–` � ' n �_ <br /> ApplicationFor 8100-Dept.• _ .�i <br /> PUBLIC WORKS PERMIT PuelalnlFeeFoo $ <br /> Lesa ApP�Fee Pnia ��— <br /> eain��e ouo 5 c�0 � <br /> Print or Type Only <br /> f11 �i ��1=�1� � � ��l� �r C.r,�1Ei2 �?iJ i��-I F�_� G�Cy�. 7�l��,���� <br /> Owrier Mailing Address City Zip Phone <br /> ,� u�vr�� ����r��,�` �� i ��a�' Aur- S� i�rN��(_ �<��i2 �lS !-l[Y�� <br /> Applicant Mailing Address City Zip Phone <br /> Describe Proposed Work n ���� �7t�- <br /> W <br /> P�oject Address(if known) 3� — E. � G/LC fJ✓E, � <br /> Attach four(4)copies of plans lor proposed work• Draw to scale and note the lollowing as applicable: � <br /> • Property Lines . • Centerline of slreet � <br /> • Outline end dimensionc of all existing and • Indicate North <br /> proposed siructures on the lot • Show any proposed greding changes <br /> • Existing and p�oposed utililies • Show measuremenis /� <br /> W <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1. All calls for inspection shall be made 24 hrs. in advance- phone 259•881 5. � <br /> 2. All work shall be performed in accordance with ihis permit antl current City ol Everelt Design and Constructlon <br /> Standards and Specificationw <br /> 3. Call Location Underground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1•800-424•5555. � <br /> � /�f�TG</ SE�T�Ern�NT 9.Poc.�O �J'FwE�P CCF:9�v-OUT.-r O <br /> �y�/ /�.�/vEuJ.9,/ To Tifc SA. TiSi�9C7i0ill OF T•Y£ <br /> �U�3c/G uJa.e,CS 1�Si'ECTu%'. � <br /> S. T.rlSr,9LC ��,�y��,�«s �,�� ��� ;�� v�u,.�- 5,���Ts N <br /> c���-�,�' ����—,�G� � r,-V:�. �r� O <br /> �I%� a <br /> � ������ <br /> ACKNOWLEOGEME��T OF CONDITIONS <br /> The undersigned owner/applicant heieby agrees lo hold and save hann- <br /> less the City of Everett from any ard all claims for damages, costs, <br /> ��, expenses, or cause� of action that may arise because of installation <br /> ��( i.�/� /J� � � �7 and mainlenance of Ihe improvement or olher right�ol-way use hereto <br /> ' /iU' C�Cr�f� � applied for and furiher n�rees lo remove same upon notice from the <br /> ApproveJ for Consiruction Date City and to replace public pr�rty damaged thereby. <br /> �-� S <br /> FINAL INSPECTIOW �a�e I ' �= a���7L`-��Q� i3 8 <br /> Approved as Constructed igr� ure ot pplicanl a�� <br /> WORK AUT IORIZED BY TIiIS PERMIT MUST BE STARTED WiTHIN <br /> everett PUBLIC WORKS DEPARTMENT 180 �PYS OF D;,TE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar 5treet BE 61�1u'ENrLY PURSUED TO COMPLETION. 7HIS PERMIT MAY BE <br /> Everett,WA 98201 CANCEILED Bl'THE CITY UPON ANv STOPP.4GE OF WORK ON THIS <br /> Phone: 259�8815 PROJECT OVER��0 DAYS DURATION. <br />