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� r._+s <br /> � • I � <br /> � <br /> � F'38_ 3�7/ I <br /> / S�� Publ¢Wo�Ma Peim�l• <br /> Date � � <br /> Blaa Depl � I <br /> Applir.alion For li <br /> PUBLIC WORKS PERMIT `°°"`"'°`""`° <br /> Totalfxe S <br /> �c� Less PDn�Fec Prid 5� <br /> t�� a,�r�«o�e s 2O� <br /> �'� Print or Type Only <br /> AH Iay�n <br /> q� � �y��7 j , � �v�i-�r n� ��..� �F'1�- ���03 � <br /> H �� �1��1f�1��� ( y'��1����—�� i Phone � <br /> K y� Owner ATailing AddrCss� C��Y �� ', <br /> il <br /> � N"'�-0 `.�_J�^.�.l.�{-l'. <br />� H y~ Mailing Atldress Ctly Zip Phone <br /> x Applicanl <br /> � �d ��ln'�/�/�r I <br /> Describe Proposed Work <br /> " �g ''� � <br /> c�� o I <br />' '~:, H� <br />'I � y y � � '� <br />, g ��-��� nrn�r� �-- � � <br /> n �y Prolec�Address Iil known) � _� <br /> � <br /> � Attach lour(4)copies ot plans lor propused work•Draw lo scale antl note ihe lollowing as applicable� � <br /> • Property lines • Centedine ol streel <br /> � p(yp • Outline and dimensions ol all ezisting and • Indicate North <br /> proposed structures on Ihe lot • Show any proposed gratlin9 changes <br /> • ExiSting and prOpoSed u�ili�ies • Show measurements M <br /> W <br /> DO NOT WRITE BELOW THIS LINE O ' <br /> PERMITCONDITIONS � ' <br /> 1.All calls for inspection shall be made 24 hrs.in advance-phone 259•88�0. <br /> �,� 2,All work shall be performed in accortlance with this permit and currenl City ol Everett Design and Construction <br /> Standards and Specilications. � <br /> '' 3.Call Location Undergrou�d Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800•424•5555. 1 <br /> � O `" <br /> � � <br /> � � <br /> �� "� <br /> � � <br /> w; N <br /> '`'� O <br /> a <br /> �-�� � <br /> ACKNOWLEDGEMENT OF CONDIT�ONS <br /> '� The undersi netl owner/applicant hereby agrees to hold and save harm� � . <br /> � < <br /> '� less the Gry of Everett Irom any and all claims for damages, cosla ���`�a�� <br /> ' ��9 ����� �//Or, expenses, or causes ol action that may arise because of installation � <br /> � UO and mainten2nce ol the improvement or other nghl�obway use herero �� <br /> + applied br and �urther ac�rees lo remove same upon notice irom the <br /> Appwved lor Cons ction Dale City and to replace puhlic property damaged Ihereby. .� <br /> �/� ^ � �� 7 /- <br /> /( r' �Ll��" l�/5�3 7,,r..�cc.� (�1� (/�+-....lixl�e f d3 Sb'' <br /> fINAL INSPECTION � ��� - Date <br /> Approve d a s C o n s i r u c t e d Signature ol Applicant <br /> WORK AUTHORIZED BY THIS PERMIT U:>T BE S T A R T E D W I T H I N <br /> everet� PUBLICWORKSDEPARTMENT 180 DAYS OF DATE PERh11T IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILIGEN7LY PURSUED TO COMPLETION.THIS PERMIT MAY 8E <br /> Evcrett,WA9B201 CANCELLED BV Thl[CITV UPON ANY STOPF'AGE OF WORK ON THIS <br /> Phone�.259�8810 PROJECT OVLR 90 DAVS DURATION. <br /> � <br /> �� <br />