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4 <br /> DetB !/J '1/ . .., , . a„oecwo�xsae�mn. <br /> Applir.a�ion For eiaq oec�..�L•'�.!`'`G i3 <br /> PUBLIC WORKS PERMIT P�°���W���sF�� -- <br /> y O N iotni Fce 5 _ . <br /> ��� less ApPI Poe Pai� $ <br /> ��H Print or Type Only e�����a o�� s <br /> >H cn <br /> H ��. <br /> i! C] �i�/J/1Y ✓'�/�N_ /''.(� `/J).� /.��C2l7i�niT L� G�i > SL•�� JS�1 —c/ '.iS� <br /> C x O �wner Mailing Atltlress City Zip Phone <br /> 'zJ H'sJ . , <br /> y �r .;_'�.! ��-'.�-�-m .. <br /> � O� � ApPlicant Madmg Adtlress Gty Zip Phone <br /> HC <br /> OH <br /> H �� Describe Proposed Wa�k 3e y .s' 1' /-,C..G�� -.� ,J�F/C- <br /> �V �] <br /> ta" y� — <br /> "y W <br /> g �' — <br /> H 1713 � <br /> O Cy Cn Projec�Atldress(II known) ��.3'Ln-»cn�✓(' • <br /> � �� Atlach tour(4)copies o� plans lor proposeA work� Draw Ie scale antl note Ihe lollowing as aPU�i�ab!e. � <br /> yO� • Properly Lmes • Centerline of stroct � <br /> • Ou�line antl dimensions of all e�isting anq • Intlicate Norih <br /> propOsed 5iructure5 on the lot • Show any propos�'d pradinq Utanqes <br /> • Existing and proposetl Wilities • Show mea5ureinenr, � <br /> DO NOT WRITE BELO�V THIS LWE <br /> PERMIT CONDITIONS O <br /> 1.All calls lor inspection shall be made 24�rs.in advance-phone 259•8810. � <br /> ,�o... 2.All work shall be p,:Aormed in accordance with this permit and wrrent Gty ol Everett Design and Construction <br /> �� Standards and Specilications. <br /> 3.Call Location Undergmund Service 48 h�s.belore you tlig.TOLL FREE NUMBER 1•800•424•555Fi. � <br /> �� � O <br /> .w.� <br /> __'', � <br /> -..� <br /> -��i��,�—� �_ O:fl�_1=�'- i�1`��Z (`=`.C:=i�J l iz�:= L <br /> s - �.�- ���_, � <br /> _ 0!� 1 + �c�-„It l`_'�= c�. <br /> � ._ <br /> a <br /> y ACKNOIVLEDGEMEN70FCONDITIONS <br /> i� � The underspned owner/applicant hereby a9recs to hold and save harm- <br /> less Ihe Gty ol Everelt Irom any and all claims lar damages. costs, <br /> expenses, or causes ol actlon that may arise �ecause of installation <br /> and mainlenance ol Ihe improvemenl or olher right-obway use hereto <br /> Approved lar ConslruCtion Date applicd lor and Iu�Iher aqrees to remove same upon noticr Irom the <br /> Cily and to replace publlc property dama9ed Ihereby. <br /> FINAI INSPECTION Dale <br /> Pnpio;ed as Conslruded Signalure of Applicam p;��i, <br /> evcrrtt PUBLIC WORKS DEPARTMENT WORK AUTHOR12ED E3Y THIS PERMIT MUST BE STARTED WITHIN <br /> 0 3200CetlarSireel 1&0 DAYS OF DATE PERMIT IS ISSUED AND THER[AFTEF IS TO <br /> Everel6 WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS P[RMIT MAV B[ <br /> Pha��.z59�t3P�� CANCELLED BY THE CITY UPON ANY STOPPAG[OF WORK ON THIS <br /> PROJECT OVER 90 DAVS DURATION. <br /> 1 <br />