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1 <br /> Dei? 2 3 � n�oi��wo�.s r��m��. 8�- �� — <br /> Applicalion For ame o�o� • ��L�Lg <br /> PUBLIC WORKS PERMIT Py11TotnlFeeFee S — <br /> �ess noo�Fcc va�a S <br /> Balanca Duc $ � <br /> Print or Type Only <br /> • 17�/l�n� l�/.r�fl�G � � Zi.�Lr � ur-'/J iGD 77d'7� /(/J- �`/J - �i�.l��•/ <br /> Owner Mailing Address Cdy ' Zip Phone T <br /> ��,� .i l�is- ���z� - ,y;� �. �,.� y�oz� ���- �4.�0 <br /> Applicant MailingAddress S,G City Lp Phone <br /> Describe Proposed Work d�Gl+l (�'c2/Si. �r �, �r�..t��n•�G <br /> S /�,c'i = �.-�.rt 1/���= LO� �. S 1� 1 zAZ- �s� 7 <br /> Q W <br /> Prolect Address(il Imown) T 70-�— /SY/��/_F, Sr � <br /> Atlach four(4�copies ol plans lor proposed work- Draw to scale and note the lollowing as applicable: � <br /> • Property I.ines • Centerline of street ♦A <br /> • Outline and dimensions of all eaisting and • Indicate North V� <br /> propased structures on the bt • Show any proposed gr:ding changes <br /> • Exisling and proposed ulili�ies • Show measurements � <br /> DO NOT WPITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1.All calls lor inspection shall be made 24 hrs.in advanc.-phooe 259-88�0. � <br /> 2.All work shall be pedormed in accordance with this pern�it and current Cily of Everett Design and Construction <br /> Standards and Specifications. <br /> 3.Call Location Underground Service 48 hrs.before yau dig.TOLL FREE KUMBER 1•800•424-5555. � <br /> O <br /> � <br /> N <br /> O <br /> a <br /> ACKNOWLEDGEMENTOFCONDITIONS I <br /> The undersiyned o�vneyapplicant hereby agrees to hold and save harm� <br /> less ihe City of Everett Irom any and all claims for damages, cosls, <br /> �� � � � /� expenses, or causes of action Ihat may arise because of inslallation <br /> �'1x�U(.CJ �Oafr1- 2//D8 and maintenance ol �he impwvement or other ri�h�-ohwaY use hereto <br /> applied lor and lunher agrees lo remove same upon notice Irom Ihe <br /> Approved fo Gonslructi Date City and to replace public property damagetl thereby. <br /> / � <br /> � E���,- �/�/� Q - � <br /> FiN—nTs�a criora Date � � —' 2— Z 6—�R <br /> Approved as Consiructed Signat e ol Ap�li a D�le <br /> everMt PUBLIC WORKS DEPAFT�1ENT WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN I <br /> � 3200CednrStreel 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> BE DILIGENTLY PURSUED TO COMPLETION. TIiIS PERMIT MAV BE <br /> Everett,WA 98201 C�NCELL[D BY 7HE "�TY UPON ANY STOPPAGE OF 1NORK ON THIS <br /> Phone�. 'S9-E1t710 pRpJLt;l OVEH 90 D� .3 DUfL1TION. <br /> � <br /> � � <br />