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�� � <br /> c>y y '/' .p 1-� -Zq-Zfl-9' <br /> t" Dat9-K�- /L a�m��wo,x.ve,m�i. �- <br /> ��� D��p Deo� • Q <br /> Application For <br /> ��� NUBLIC WORKS PERBVIlT °�°,o,aFoeF�� 5 <br /> N H <br /> LessFOC� FeePaiU S <br /> O�.Qj. � PrintorTypeOnty TO P STING � � Z"�l�_ eai,�ceme 5 2�` <br /> ��g o,� r h P_�n�,a <br /> c�" " .To� �U511F� ��3 S - � .nr. St �,U �?'�o� 353-�/39� <br /> ��� Owncr Mailing Atldress City Zip Phone <br /> 8 N H _ ���it/.�r <br /> n d y ApPlicant blailing AJdre55 City Zip phone <br /> � � Ocscribe Proposed Work ,v Q- � n� '� �Q� I I�l�_S, <br /> HOfyi� <br /> - W <br /> ProjectAtldresspfknown� a-�Z31- �-yT D2_SF, L <br /> r <br /> Attach lour(4)copies of plans for proposed work- Draw to scale antl note the lollowing:�s apPlicable� � <br /> • Pronerty lines • Centedine ol streei <br /> • Oulline and dimensions o�all existing antl • Indir.ate Nurth ' <br /> proposed struclures on Ihe lol • Snow any propased grazy5pJ3dw(fl�r31�16AN OOOAN4691 �K '�1.�� <br /> • Existin� and pioposed ulilities • Show measurements � � <br /> DO NOT WRITE 0[LOW THIS LINE �� f54S.00 O <br /> PERMITGONDITIONS FLEG 450.OD <br /> '�1 t.All calls for inspection shall be made 24 hrs.in advanre-phone 259•881 O. MECH 560.00 <br /> 2.All v,�ork shall be pedormed in accortlance wilh ihis permii and current Cily ol Everett Des�c,���Ronstr��� � <br /> ' Standards and Speciiications. �Gpp�� f4.50 <br /> 3.Cail Location Undergrountl Service 48 hrs.belore you tlig.TOLL FREE NUMBER 1-800•SZsi=5555. � <br /> � URVWV 820.00 <br /> s N000260.i7 <br /> � 1 SEI�R 830.00 O <br /> ��' FNDIIi 83:�0.00 <br /> 1171-5 �650.00 <br /> '�' CHECI; 5174�.00 � <br /> 1_1 (/� <br /> I-1 � <br /> _� a <br /> _� <br /> I� / YIn/ ACKNOWLEDGEMEN70FCO�JDITIONS <br /> ! ��'"�1 „ The undersi[�netl owner/applicant hereUy a9rces to hold and save harm- <br /> ' '� '• Iess the City ol Everel� Irom any and all claims lor tlama9es, costs. <br /> � — // expenses. or causes of acBon Ihat :nay arise because ol installalion � , <br /> _' `� �_ ����� /�_��[_fin anA maintenance ol �he impiovemant or other ngh4of-way use herelo �', <br /> �,KU/ ap�llmtl br and Iwlher a9rees N remove same upon nolice Irom the i <br /> - Approvetl I Conslru ion Date Cit and to reU��[e puUlic prooerry damagetl there6y. <br /> ! �� / 3 , '�// <br /> FINAL INSPECTION Z Date � l�f� ' �L��/""'y <br /> Approved as Constructed Si� n�ure ol Appfican� Dale <br /> c�rren PUBLICWORKSDEPARTMENT �N RK AUTHORIZFD BY THIS PEPMIT MUST BE STARTED WITHIN <br /> 0 3200CcaarStrcet 180 DAYS OF DHTE P6RM111i IS ISSU[D AND THEREAFTER IS TO <br /> EveretL WA 98201 BE DILIGE�TLV PURSU[D TO COMPLETION. THIS PERMIT MAY BE <br /> Phone'259�9810 CANCELLED PV THE CI7Y UPON ANV STOPPAG[OF WORK ON THIS <br /> ' PROdECT OVeR 90 fJAYS DURATION <br /> � <br />