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� �-- / <br /> I1 /,(1I4d �` 9o/22d <br /> Date�.(�+�}- Pu�lm Worhe Permlt• �� <br /> •/ ' � B�aO.Deat• g r//!7 �4 <br /> Application For � �/� ' <br /> PUBLIC WORKS PE�iMIT Pu�i¢WorksFee <br /> Total Fee s <br /> p Less Apol.Fee Paia S <br /> o O P V�] O p V�l O a BaianceDue S 2 � <br /> L <br /> Print or Type Only ¢ ,v o a o �i a ci o- <br /> :: .�.+ b � R� .�-�+ � w M <br /> .�y M tll w <br /> ('� ' ( ^,� .-� � J M . <br /> n- � F� II rrrll7" /2��g� �,1G�7��,� ht�/ <br /> � Br d�—S � <br /> wner MaiHngAddre�s � rl � c-i �[� � Zip Phone7�l _ <br /> � oau°�S > `�bo � w � <br /> �� �Co 5� 1 /-�w�i � "L�y�iycv�'r�� ��j'4—��p�]3/G/ lSss <br /> Applicant Mailing Addre s C� ZiP Phone <br /> Describe Proposed Work �p��) Q Q!Q�r+ <br /> .� _ W <br /> Prolect Address lif known) n� � - � -- � <br /> �i�k V___,__�1/� T. . _ <br /> Attach four(4)copies of plans lor proposed work- Draw to scale:+nd noi�ihe lollowing as applicable: � <br /> • Property Lines • Centerline of streel � <br /> � Outline and dimensions of all existing and • Indicate North <br /> proposed siructures on the lot • Show any proposed grading changes <br /> • Ezisting and proposed u�ilities • Show measurements M <br /> W <br /> DO NOT WHITE BELOW THIS I.INE � <br /> PERMIT CONDITIONS <br /> 1.All calls for inspection shall be made 24 hrs.in advance•phone 259•8810. � <br /> 2.All work shal�be pedormed in accordance with this permit and current Ciry ot Everetl Design and Construction <br /> Slandards and Specifications. <br /> 3.Call locetion Underground Service 48 hrs.before you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> �• A�PI.t�P�t1T SF-k-AL.�-- VPC�ZF�PE ���5(L1� S�WG'f-�— O <br /> �C� T'l� L.1t,'C� , l••lk�it=^l2� lT '��r�.[S VrJ.Dc"1C_ <br /> 1�l�L� S"TLv �-i V f�-E. � <br /> � �'l� j�t !� w '� 0 <br /> , � �; L � ^ �� <br /> �� ��� �, � � a <br /> , �7 <br /> �I i IL / / � I/' ���`�N <br /> �� `' /, ��� ,�r ���� / <br /> 11110 U J C ''Y D � ACKNOWLEDGEMENT OF CONDITIONS <br /> �� ��� The undersigned owner/applicant hereuy agiees to hold and save harm- <br /> less the City ol Evere�l liom any and all claims for damages. cosis. <br /> expenses, or causes ol action that may arise because ot installation <br /> -�7�, Iny I/Ap^� G{ C. and maintenance of Ihe improvemenl or other rigM�of�way use hereto <br /> �-�'�"�'--'�'�`- `�¢— � � � ��� applied lor and turiher agrees Io remove same upon notice irom ihe <br /> Approved for ConsVucC Date City and to replace public property damaged thereby. <br /> � <br /> _ �,� �--;�-�-2/ �Q • n / ��-�r� <br /> FINAL INSPECTION Date ��1 N/1 �(i1 �����L��t �'�'�'/N" <br /> Approved as Constructed Signature o(A�pliCant Date <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE iTARTED WITHIN <br /> everett PUBLICWORKSDEPARTMENT 1g0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CedarStreet BE DILIGENTLY PURSUED TO COMPLETION. TIiIS PERMIT MAY BL <br /> Eeerett,WA 98201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259�8810 PROJECT OVER 90 DAYS DUf'l�TION. <br /> � <br />