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� � � <br /> � � x <br /> 1� � r� Puoi�c Warwa Pe�m�1� / �.� ��, <br /> ''� ~ Date ��G � <br /> 1C n BiEp Dept • <br /> y� ` Application For <br /> �'yH PUBLIC WORKS PERMIT °°°°`"'°""`e S <br /> y tmnl Fce <br /> � O � Le55ApOl?eePaiOS .�C)�� <br /> y � Baiancc oue 5 <br /> H <br /> (� Print or Type Only <br /> H C�7 O <br /> �� n � <br /> � '—� i ��� 1���� -i•7 �'' 1'� � ����-_�:- .� � <br /> �H � � � - n �iirl =�7G5 f���"rr..iCb+l T�' F�ti F � �:.�- - <br /> H y � Mading Address C ty Z p one <br /> wnei <br /> g� � , , , , � <br /> , <br /> O t7 p� " % � (lAI � C � 1 A//./ � <br /> C,�' C. � Mailin9 Address Ci�y Zip Phone <br /> C �:� Applicant <br /> � oy � �iD£wn��c SFc.;ia�.1 i� tao�t ��= 1r�v wa�/ <br /> Describe ProposeC Worh I <br /> � �7(11) IF;� ��f�iY\ 1 (jhi {J�11 �� (I.�:�. <br /> W <br /> Projec�Addresslifknown� �70y hiv�rVit�V 1>C✓n. - � Wr1 `?Y`•1�' � � <br /> � <br /> qttach lour(4)cop�es of Plans lor proposed work� Drav+to sc..�.a and nole the lollowing as apUhca6le: � <br /> • P�operty Lines • Centerline ol sreel <br /> • Outline and dimensions ol all eaisting v nd • Indicate Norlh <br /> prOposed SlruCtUreS on ihe lot • Sho�v any prOUoSed graGing changes <br /> • Eristing and pwposed utili�ies • Show mea5urements /„ <br /> W <br /> DO NOT WRITE BELOW THIS LINE O <br /> ' 1 PERMITCONDITIONS � <br /> 1 ' 1.All calls lor insGection shall b�made 24 hrs.in advance•phone 259•8810. <br /> � 2.All work shall be performed in accordance with ihis permit and current City of Evemtt Design and Conslruction <br /> Slandards and Specifications. � <br /> '�1 3.Call Location Underground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1•800•424'S555. <br /> � � X �c/i,:,-�� �f�i:/ .�.t(` ;ra.f'�.i CJn�.-� — <br /> � � /' / � <br /> . �c.1 �}�:�.c� 7� l.� Tc'.�r- :�c S% :�C - , �('�, <br /> � , S�zC�� � </: S.-afn L� L�/�:.:- ��,i,_ � <br /> Cu-o-.G /.�a n� ,�2�z� �t�-:. <br /> � f } • <br /> CL'`C`C�L'l�.f ,lai..:�JiC-Ci.:,� : (r-2 /Ji'1;,: � f� � <br /> � O <br /> i <br /> ! �Cr j!'.i',:c� <br /> � � � a <br /> ' f �CKNOWLEDG[M[N7 OF CONDITIONS <br /> �' <br /> Thcundersignedowner/apPlicanlherebyagreestoholdandsave iarm� <br /> iless Ihe Cdy of Everett Irom any and all claims br tlamages. costs. <br /> � J eKpenses. or causes of acllon that may arise becausr. of installation <br /> �/�,� /Y 7��,/�z and maintenance of lhe imp�ovement or other righ4of�way use hereto <br /> �� r/? �pplied lor and lurther agrees to remove same upon notice Irom lhe <br /> qpprove r Conslru �on ���e City and lo replace public proPerry dama9ed thereby. <br /> � ���� ' � � ,� <br /> � �/�/9'i � <br /> �� ,r , l 7/�� -r�2 <br /> NAL IN5PE ION -- � Sigoa�ure of ApPlicant Da1e <br /> qppmved as Constructed / <br /> � WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHI <br /> ,�� PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE PERM11IT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CedarStrect BE DILIGENTLY PURSUED TO COMPLETION. iHIS PERMIT MAY BE <br /> Everet�,WA98201 CANCHLLED E3V THE GTY UPON ANY STOPPAGE OF WORK ON 1HIS <br /> Phona 259�0010 PROJECT Ob'ER 90 DAYS UURATION. <br />