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Date �� [L� .. , �_��,����•m.,��,•� �y/ r <br /> Application for ^i,;v oro� ���/����_ <br /> r <br /> xr� <br /> PUBL{C WORKS RERMIT iveTo,eF�;`e8 s <br /> m a y Les+nooi Gee Pa�a 5 <br /> ,�'.b`.� 6aia�:-c ouc 5 <br /> a y y Print or Type Only <br /> H �3 � <br /> � y� ��"'�'►�1�1� ��>� ����� �-17� 3 �����a�i�0�r��—��1' ���y� ����—�1�35 <br /> O x0 Owner r MaihngAtldress Gly Zip Phone <br /> � V]H <br /> H t" <br /> �yx <br /> `" y� Applicant Mailing Atldress City 2ip Phone <br /> ��� Describ� Proposed Work �� u�1�yU��f�.�A 1`-�l! <br /> ay� J <br /> g "y - W <br /> � <br /> H �, <br /> � d� C%\ � <br /> CJ C r Proiect Address lif hnownl _ _ <br /> 3 L�1 <br /> z' Attach lour I4)copies ol plans lor propo5e0 work�Draw to scaie antl note Ihe lollowing as apphcabie � <br /> y�n <br /> H O q� • Property Lines • Centerlme ol slrer_t � <br /> • Outline and dimensions ol ail e*ishnq anA • Inditate NorRi <br /> proposed siruclures on the lol • Show any proposed 9ratlmq chnnges <br /> • Existing antl proposetl ulihlies • Sl�,ow mea5uremeNs � <br /> DO NOT WRITE BEL01Y THIS LIN[ <br /> PERMIT CONDITIONS O <br /> � 1.All c21151Cr inspedion 5ha11 be made 24 hrs.in advance�phone 2$9•8$10. <br /> � = 2.All wo�k shall be pedormed in aCeordan[e wdh Ihis permit and current City oi Ecerett Desi9n and Conslruction � <br /> Slanda�ds ar.d Spacitications. <br /> 3.Call Location Untlerground Service 4B hrs.before you dig,TOIL FREE NUMBER 1•800•424-5555. � <br /> � <br /> o� �V3t._.� C._ �(�IZ�S ��T� ��C-C'�>\11l_'�1� <br /> ;�n.._�.�1'�°-l:�c C. � <br /> __ _- _' „- :C i L <br /> -� ,� <br /> r- <br /> !!i � <br /> 0 <br /> i ; i a <br /> 1'"� ACKNObVLEDGEMENT OF CONDITIONS <br /> "� T!;����dersigned owner/appliCant hereUy a�-res�o hold and save harm- <br /> � less the City ol Everett Irom any and all claims lor Aamages, costs. <br /> eKnenses, or causes ot action Iha1 may arise because ol installalion <br /> . and maintenance ol the impwvement or olher right�of-way use hereto <br /> applied lor and luriher a9rees to rmnove same upon nolice ��om �he <br /> Approved for Construction Date Cily and to replace pubGc property damaged Ihereby. <br /> FINAL INSPECTION Date <br /> Approved as Construcied Signature ol Applicnnt Date <br /> evcictl PUBLICWORKSDEPARTMEN7 WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> � 3200CedarStreet 1B0 DAYS OF DATE P[RMIT IS ISSUED AND THEREAFTER IS TO <br /> Everelt,WA 98201 BE DILIG[NTLY PURSUED TO COMPLETION. THIS PERMIT MHY BE <br /> Phone:259-8810 CANCELLED�Y TH[CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> PROJGCi OV[R 90 DAYS DU(i�TION, <br />