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Dat ���}/�/K,�/�=�-(-f� � P11�IiC WOIh9 PPIT�I� • � � <br /> E� ' / Blaa Deot e <br /> Applica�ion For M <br /> PUBLIC WORKS PERMI� PuliliCWorkSfee <br /> iotnl Fee g <br /> LPSS 4Opl FY!•Pd�d S <br /> Print or Type Only $ $ $ $ ��11nCeo�� S �� <br /> � g � � � <br /> N � K• M M <br /> C;,��as �o. �x �SG ��� � cp qaos3 <br /> Owner Maiiiny �cdress-R�i 7_ip Phonc <br /> � f- r � <br /> � <br /> ,�m�btd_E��rr✓s IA�15 "1dr�� M1E 5_ � � 9�0.�? _ lau6 d5/-l.�� <br /> --- -o�P6canl tv1;,�lin:;Address Ciiv ZiD Phone <br /> Descri6e ProposeA Work ��_�jClq._HIlL�_�e—�/�`r��L-���—������S�S. <br /> S�o F_t��"�S— -.GfM�- - <br /> ���,t'�,^���_� ---- <br /> Prolect Address lii known! �a�s.ZC�k�d��C�-.�— —_ — . � <br /> Attach four(4)copies ol plans lo� nroposed wo�K � Diav: m �c,il•, .i::,� note tho lollowmg as apUlicable: � <br /> • Properry Lines • Centcriine N street � <br /> • Outline and dimensions ol all exishng and • Indicate Norlh <br /> proposetl strudures on Ihe tot • Show any r.roposed 9rading r,hanues <br /> • Existing and proposed utilities • Show measurements � <br /> DO NOT WRITE BLLOW iHIS LINE O <br /> PERMIT CONDITIONS <br /> 1.All calls for inspection shall be made 24 hrs.in advance-phone 259•8810. � <br /> 2.All work shall be pertormed in accordance with ihis permit and current Cily of Everetl Design and Construction <br /> Standards end Specitications. <br /> 3.Call Location Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1-800-424•5555. � <br /> '� G/'�wr/r�� 1F �f'J'kd/lt q' � O <br /> � /� � <br /> �S� .-P�✓os io.�� �4�'! D� � s�prca�c� ,O��r— � <br /> // / �/� <br /> Lr.v�� �'c �j �NS/� /�fu�»�+!'lB+�v� V♦ , <br /> / � O Q <br /> a <br /> ACKNOWLEDGLMENT OF CONDITIONS <br /> 1he undersiqned owneVapphcant hereby aqrees to hold and save harm- <br /> ---- --�—�� less the Cdy ot Everett trom any and ail claims for damages. cosls, <br /> J � e.pense,. or causes of action that may arlse because of installalion <br /> � � anA ma�ntenance o! Ih� .�nprovement or othe�righl�ol•way use hereto <br /> �;.pl,r;! lor and �urther agree5 Io remove Same upon nolice from the <br /> Appr d for C�on uctio ` �+��' � C��t� :v,d to replaca Uublic propertq damaged Ihereby. <br /> �j � ; � _ � �-19� <br /> ; , ; � �, � ��� -� <br /> FINALIN E ION U�« <br /> Approved as Gonslructed Si9n.uure of Apphcam Date <br /> � PUBLIC WORKS DEPARTMENT WORK AUTHORIZED BY THIS FERMIT MUST BE STARTED WITHIN �i <br /> tII0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> '�� 3200 Cedar Sireet BE DILIG[NTLY PURSUED TO COMPLETION. THIS PERMIT MA'I BE <br /> Everett,WA 98201 CANCELLED �Y THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259-8810 PqO.IECT OVER•30 DAVS DURATION. <br /> I <br />