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Date�� a�e��cwo���ac i 7V�]��{�����J <br /> ApPlica�ioc For eie9 oeo��� _��[�Sl—LtLI�J--- <br /> PUBLIC WORKS PERMIT P°°��°W°��s`�.� ----— —_ <br /> ,o���F�� $_— <br /> �ess nna.F�e vam g---a— <br /> Ualance Duc $��O <br /> Print or Type Only <br /> �f�� v�l_ ( � 5`�� 135a- � �_(Y.i�l �1 �i�f�'1�I'�'11���1 � <br /> Owner Mailmg Address �— Cdy Zip Phone <br /> �v(/' l�� blS//) r()I� <br /> Applicant Ma�iing Atldress City Zip Phone <br /> Describe Proposed Wark _ � ` � � <br /> - W <br /> Prolect Atld;ess lil kn^.. .1 __`�� �`/l� ,�� � <br /> Attach four(4)copies ct pl��;'or proposed work- Draw to scale and note ihe following as applicable: �� <br /> • PrOperty l��ec f CentedinE ol 51reet � <br /> • Outlme and dhn�.nsions of all eaisting and • Indicat� �Jcrih <br /> propo�:eU st:uclures on the lol • Show any proposed gradinq changes <br /> • EKrsti,ig uid proposed utilities • Show measuremeNs � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1.All calls br inspectlon shall be madc 24 hrs.in advance-phone 259•8810. � <br /> 2.All work chell be pedormed in ac^ordance with this permit and current City ot Everetf Design and Construction <br /> Standards and Specilications. <br /> 3.Cali Localion Underground Service a8 hrs.before you diq.TOLL FREE NUMBER 1•800•424•5555. � <br /> O <br /> � <br /> � <br /> O <br /> � <br /> ACKNUWLEDGEMENT OF CONDITIONS <br /> The unAcrsic�ned owner/applicaN hereby agrees to hold and save harm- <br /> less Ihe Cily ol Everelt Irom any and all claims br Aamages, costs. <br /> '�� 9l <br /> � / / exper,ses. or causes of action ihat may arise 6ecause ot installa�ion <br /> 'f'� �(�'� /J�/ G.�_�� pp and maintenance ol the impruvement or other righ�-ohway use hereto <br /> 1�A 6''I / � applied for and furlp gr o remove same upon nolice Irom the <br /> �pprov o Construct on Dale City and t r aJ�cr�public pro e damaged thereby. <br /> /�+ �O ,���� �f�S/� ��/�Li.�{,�`� G/��'Lu 5 `�C. '-c�/ <br /> ,-!� NA� INS ION � Date � _ <br /> ApFroved as Conslructed Signa(ure ol Appllcanl Dale <br /> WORK AUTNORIZED BY TH�S PERMIT A9UST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPARTMENT 180 DAVS OF DATE PERh71T IS ISSUED AND THEREAFTER I,�'. TO <br /> � 3200CedarStreet BE DILIGENT�Y PURSUE� TO COMPLETION. THIS PERMIT MAY 8E <br /> Everolt,WA 9920t CANCELLED BY THE C1TY UPON ANY STOPPAGE OF VJORK ON THIS <br /> Pnone:259•0810 PRUJECT OVER 90 DAVS DURA?ION. <br />