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�r� <br />n <br />a�H <br />ti <br />y �H <br />�e o <br />O x0 <br />'?1 H'�J <br />V7 H <br />y r <br />�i o �i <br />H C7 <br />H/��O <br />y� V Cq] <br />9 H [�7 <br />r x <br />Hy <br />g�' <br />H <br />�e� <br />��� <br />z y �n <br />H O tn <br />Date�� <br />Applicahcn For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />7 <br />pwnei <br />c� <br />, j ��/ <br />P„ lN�.c WarhS Pe t ei:11J~'v`/ <br />Ir,�na oeoi.. .�_ !� _ _.. <br />PuLI�c Woi�s Fec <br />rar� re.� 5 <br />LessAnn� fe�Va�J S <br />palan�:r0uc S <br />Add�ess � Cdy Lp Phone <br />f 1 �� <br />i.pphrant MaiLng Address GIY LP Phone <br />Descnbc Proposetl Work �—l..:i.�L�-�u� -- <br />Proiect Address I�I knownl <br />A�tad� �our 1�) copics ol Plans lor Pmposetl wo�k � D�a��+ in srair .inA r,otc Ih� followmg as apPhcobir <br />• Property Unes • Centedme ol streel <br />• Outl�ne and dimensions o� alt e�i�,tmy and • I�d�cate Norih <br />p�nPos�,U s�rutture; on Ihu Ini • Show any ProPoSrd ,r,�dinr, chanycs <br />• Erisf�nq and propOSCd ubhhes • S��o�v medsurumenls <br />LON' iHlSll <br />PERMIT CONDITIONS <br />t. All calls Ior inspection shall be made 2n nrs. in ativance � pnone 259•8810. <br />2. All work shall be pedormed in accortlance wlih Ihis permil and current Cdy of Everell Design and Construction <br />Standards and Specllicalions. <br />3. Call Localion Under�round Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />Approved lor Construclion Date <br />fMl.L INSPECTION <br />AnP�oved as ConStructed <br />i•��i.��q� PUBLIC WORKS �EPARTMENT <br />� 3200 Cedar Streel <br />Everett. WA 98201 <br />Phane:259�8810 <br />Dalc <br />��t� ��- <br />,. <br />,. <br />,�; , . _ - <br />,: _ :- ; <br />W <br />� <br />�w <br />� / <br />Z <br />O <br />� <br />� <br />O <br />a <br />ACKNOWL[�G[MENT OF CON�ITIONS <br />Thu undersigned ownri/apphcant hereUy a9rees to hoid antl save harm- <br />less Ihr. Cdy of Evmett Irom any and all claims for domages. costs. <br />expenses, o� causes of act�on �hal may arise because ot installation <br />and mamlenance of �he improvemeM or o�her righPot�way use hereto <br />appiied lo� anA Iwthei aqrees Io remove <�me u�on notice from the <br />City and lo ieplace pubhc pronerty damaqed Ihereby. <br />Siqnatwe ol APPlicant Ui°`' <br />WORK AUTIiORIZED BY TIilS PERMIT MUST BE START[D VJITHIN <br />180 DAYS OF DATE PERM1IIT IS ISSUED AND THEREAFTER IS TO <br />BE DIUGENTLY PURSUED TO COMPLETION. THIS PERA1IT M�Y BE <br />CANCELLED BV THE CITY UPON ANY STOPP4G[ OF WORK ON THIS <br />PROJ[CT OVER n0 DAYS DURATION, <br />