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H <br />��1� <br />Q�H <br />�Htn <br />H�� <br />K O <br />oH p1 <br />�9�� <br />� <br />H� <br />OHd <br />��g <br />�i:Y (�] <br />t"y�L <br />HH <br />gN <br />� Gt7 V� <br />[9 <br />HO� <br />Date � � � <br />Applicalion For <br />PU�LIC W�RKS PERMIT <br />Print or Type Only <br />�.w �% f (c l�i i ��eiJ <br />Mailing Address <br />i' m.�-l- � i. c �� 1— <br />Mailinc� Address' <br />�f / <br />Publit WO�Fs Pa�mil • �.��'O�/[�1 " <br />Biep Depl. ♦ �%Ci(�ri.�/�.� <br />PuEL<WorMafec S <br />Totrl Fec <br />Less Roo� Fec PoiU $ — <br />001anCe DuC 5 � � <br />[—vp�� w�. �8Z6� 33k - <br />City Zip Phor <br />�� Sl � Mu k� I-I—e.c �N z7� 35`. <br />Citv Zip Phor <br />Oescribe Proposed Work <br />Ac�� ; ���w.. d-a C'„ n.,.f. �.e, <br />Proiect Address Iil known� — — q000239'%3 <br />Attach lour (4) copies ol plans lor proposed work - Draw to scale and note ihe lollowing as applicable: eL� � 5108.� <br />• Cent�dine ol slreet ;4 50 <br />• Properry Lines E SRCH � <br />• Outline and dimensions ol all existing and • Indicale North n� 520.00 <br />proposed sinicW res on ihe lol • Show any proposed gradir�g���anges <br />• Esisting and proposed utilities • Sl�ow measuremenls CHECI: 413�.5� <br />'�' PERMIT CONDITIONS <br />1. All calis for inspection shall be made 24 hrs. in advance • phone 259•8810. <br />�' 2. All work shall be pedormed in accordance with this permit antl wrrent City of Everetl Design and Cons�mction <br />� Slantlards and Specifications. <br />3. Call Location Underground Service 48 hrs. belore yo� diy. TOLL FREE NUMBER 1•800•424•5555. <br />�j, �lolZ TU 5r/�!z"i�NC� �,i�oENi�.ic� ai ��vw�`� <br />��Piz�M CvN�KT r�N,�i� S ��A-BL�i�-r.9,�/ Q 339- �O3 <br />O�'- 2�-j -S��G �c�� i�c-s�c„�/ c�cws��� Nnat�'- <br />� � --,��� <br />F proved I�lr�c�ion , Date <br />i <br />�/b�l /,'�—r' �!'�d <br />�� ��' Date <br />FINAL INSPECTION <br />Approved as Construcled <br />everelt PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar ftreel <br />Everell. WA �J8201 <br />Phone: 259�8010 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />O <br />I"' <br />� <br />0 <br />a <br />The undersigned owner/applicant heieby agrees to hold antl save harm� <br />less Ihe City of Everett Irom any and all claims lor damages. cosls. <br />expenses, or causes of action Ihat may arise because of installation <br />and mainlenance ol the improvement or other ric�h4ol�way use hereto <br />applied lor and further agrees lo remov^ same upon notice �rom Ihe <br />C�ly and lo Hplace public pmperty damagetl thereby. <br />/• <br />� �� ) � <br />l.1/!c`�x/ �� "� '�_i�j��C� <br />� Sic�nalure ol Applicant � D.,te <br />WORK AUTNORIZED BY THIS PERMIT NUST OE STARTEU WITHIN <br />1B0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT �1AY BE <br />CANCEL�f:D BV THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECi OVER 90 DAYS DURATION. <br />