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o2�eL1-►� � <br />Applicatien For <br />PUBLIC WORKS F�ERMIT <br />T� �nsTiN� �—z<<��� <br />Print or Type Only <br />Applicani <br />DesCribe Proposed Work <br />ng <br />Mailing Addmss <br />Prolect Address Id known� � � � UZ 32.. �J pL SE <br />�„�,�,�,vo,�,�„ /((//yy�''s�--��J1 <br />Ninq Dcoi � .�_/__L'�J `� <br />N�„��,,,a„s��� -- ---- --- <br />,��a� F�� s ___ <br />Less/npl FnePaN S /'� _ <br />�alln[r��n .� �F /� — <br />Z�P Phone <br />Attach lour (4) coples ol plans lor proposed work - Dr;�w to scale and note the following �s applicable: <br />• Prope�ry Lines <br />• Outline and dimensions ol all exishng anA <br />proposetl structures on the lot <br />• Existrt�y �nd proposed uti6ties <br />�r <br />• Centerline al street <br />• Intlicate Norih <br />• Show any proposed gradmg changes <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calls lor inspection shall be made 24 hrs. in advance - phone 259-8810. <br />2. All work shall be peAormed in accordance with fhia pe�mit and current ;,ity o°verelt Design and Consiruction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you C r,. TOLL FRE•' NUMBER 1-800•424•5555. <br />�� � � — <br />- _��gr.x.K ,1 c�::p� ��_ Lv_.�; <br />... �+._—_—__. <br />� � � n ,1 L ['�rr��s�'�c.���� Date <br />/ i <br />FINr��/ l � �,<{�]".:'_.i 1�i��� _� � , � <br />� II�`r�E(:TI !!i 'r�'~ �j � / �jb �e <br />Appioved as Cnnstvcted <br />I sv�i, =UB�IG6VORKSJC�`ARTMENT <br />?2J5 Ceda� Slree' <br />Lverett. WA 992U�� <br />� Phone:259�Bd1U <br />�__ <br />�I <br />ACKNOWLEDGEWENT OF �ONDITIONS <br />W <br />� <br />� <br />N <br />� <br />O <br />■ <br />� <br />0 <br />a <br />The ��ader;,iyned ownedappiicant hereBy agrees to hold and save harm- <br />Iec � Gry of Everetl irom any a-�d all claims for Aamages, cosis, <br />ex � .�s, or c.�ases ol actior that may arise because ol mstallation <br />�. J?:�snie of the in+provoment or other rigM-ol-way use herelo <br />�+ � b� BnC �urihai ag�ee:: �o ren�ocC same upon notice irom ihe <br />C.��c i�� �: p'aae pub�a pro�nry damaged !hereby. <br />r <br />;��, ��'� �` /—�/-�)� <br />� . �✓ '� �. ��� <br />,Siqr2ture AppliCan� Date <br />�WOfiK AUTHOqIZEL BY 1H15 PERMIT MUST BE STAFT'cD WITHIN <br />180 MYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO .:OMPLETION. THIS PERhIIT MAY BE <br />Cl,NCEILhD BY THE C� i Y UPON AkY STOPPAGE OF WORK ON THIS <br />PhOJ'tC7 pVEF. 30 DAYS DURATION. <br />