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1 <br /> 3 � �J� ��J� <br /> Oate_ r 1 � P���IicWorFSPor <br /> , ^l <br /> '� Anplir.alicn For mng o�o� •� D�Cl7'(- � <br /> �_ _ <br /> PUBLIC WORKS PERM►T �°°�,—°w°,�:��° <br /> r��a�F�� 5 -- <br /> LessPno� �e�PaW S —.__ <br /> ��� PrintorTypeOnly o��;��=�o�� 5 __ <br /> ny ` <br /> �1 y <br /> C H ��P��r a�� Il�t�'' Av� �� �c.(P. �iy�� -���� <br /> r-�i y� Owner Madmg AAAress G�y Zip Phonc <br /> i-C �e� IA e� <br /> H xl -- <br /> � H� APPlieanl Mai6n�Addre;s GIY Z.ip Phone <br /> (p H --T— —C n f� <br /> xx S Desc�ibe Proposed Work 1 � ���f� -/��,-J �� � ^ <br /> [+J O ti7 --- <br /> H C7 <br /> p H —' <br /> � �g <br /> �V n � <br /> rH� PwjectAddressl�� known) I� ,I��1� — � <br /> g y At�a[h lour(4)copies of Glans to�prupoSeA work� Draw to scale antl note Ihe follovnng a p cable: � <br /> H <br /> O Cy V7 • Property Lines • Centedine ol street /^ <br /> • Outline and dimensions ot all existing and • Indicate North V� <br /> � ��r.-, proposetl structures on ihe lot • Show any proposed grading changes <br /> Z H U� • Erlstinp and prouosed ulilities • Show measurements � <br /> H O fn <br /> DO NOT WRITE 6ELOW THIS LINF <br /> PERMIT CONDITIONS O <br /> 1.All calls for inspection shall be made 24 hrs.in advance-phone 259•8810. � <br /> 2.All work shall be pedormed in accerdance wilh ihis permit and current City ol Everetl Design and Constiuction <br /> 'i Standards and Specifications. ' <br /> 3.Call Location Underqro�nd Sen�ice 48 hrs.bebre you dig.TOLL FREE NUMBER 1•800-424•5555. 7 �� <br /> �� w ` <br /> ,�� ,�� ��� //�� ,����' ��,�`.,��� � <br /> � 7-a�-89 �' <br /> I '� � � <br /> a � O <br /> '�' °- I <br /> P.R` " <br /> �I ACKNOWLEDGEMENT OF CONDITIONS <br /> T;ie undersigned owner/applicant hereby agre�s to hold and save harm� I <br /> less the City ol Everett Irom any and all claims for dama9es. costs. <br /> ' exu�nses, or causes of action �hat may arise because ol installation I <br /> '.� and maintenance ol the improvement or oth=r righl-oFway use hereto <br /> applietl for and furlher ac�rees to remove same upon notice irom the ' <br /> Approved lo�Construction Da�e City and to replaCe ouUlic property damaged Ihereby. � <br /> ��� I <br /> FINAL INSPECTION Date I <br /> Approved as ConstruCted Si9nature ol Applicant Date . <br /> everetl PUBLIC WORKS DEPARTMENT �NORK AUTHORI2ED BY THIS PERMIT MUST BE STARTED WITHIN <br /> 0 32o0CetlarStreet 180 DAVS OF DATE PERId1T IS ISSUED ANJ THEREAFTER IS TO <br /> Everett.WA99201 BE DILIGENTLY' PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> Phone:259�8810 CANCELLED BY THE CI iY UPON AN1'STOPPAGE OF WORK ON THIS <br /> PROJE�T OVER 90 DAYS DURATIGN. <br />