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��� <br />Dat <br />i� <br />- i Application For <br />PUBLIC WORKS PERMIT <br />Print orType Only <br />Piupc lYn•�s Pr.nil + <br />Eiia3 UeD� s � ... <br />Pu01m Wo�ke fee 5 <br />Tot�l Fae <br />Lesa �OC� Fee Pa�d $ <br />eelance D�e S — <br />EA 2✓on�iK /oJ6: �/Y.�*✓c s.: Edf.zc�r e%_ 35!7- Zbia <br />Mailing Address Cily 7_ip Phone <br />Owner <br />L=A-G�-t G6✓cf Ca,��r. <br />Describe Proposed Work <br />S 7/ 4 /S.. .vn S� N£ <br />Address <br />rr ✓�, •-� 7 8� �o � 5'a - i s s7 <br />�Z �� <br />.�.(�C' cNA.✓uMC FEwlcy- /� BGN�,✓/J S/JG t✓Ac.c ON <br />�c.� AC6s� 6ATE R'2 <br />T'w/. ir�e• prope'f nw,lfr G✓.✓- I'1C.)r...se_ <br />f <br />y r� <br />Projec� Address (if kn n) ��� �n '�' — <br />Atlach !our (4) copie5 0� P�ens-br-pra�nsca-wa�rc - ��ev <br />• Property Unes <br />• Ou�line anA dimens�ons ol all eaisling and <br />proposed strudums on the lot <br />• Faisting and propcsed utilities <br />STG.CEEit !i�✓�si< <br />�_L�r `/— <br />and nole Ihe foliowing as applicable: <br />• Cr.nterline ol street <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measoremenls <br />PERMIT CC NDiTIONS <br />1. All calls for inspeciion shzll be made 24 hrs. in aCvanr,e - phone'l59•88� 5 <br />2. All work shall be performed in acoordance wAh thls perm�i and cwreni City ol Lveretl Desiqn and Const�ucbon <br />Standards and Specifications. <br />3. Call Locatlon Undergreund Service a8 r.is. b��Jcre you dig. TOLL FREE NUMBER 1-SOO•424•5555. <br />��-; .( � ,�_�^ ��7Z�--�-�= �, � — . <br />//�//. .� <br />/`/ /'"J� /� / <br />/� �,4 _ ,�1 / /Z /`�� f/L'"1'� �,L ��/ r . _. � f / �. - <br />L — S �.y tLGf� <br />� <br />� <br />�� � /!;.i.� _,i� �-� _ <br />".�' � j 7 ;- . <br />,� � <br />/ � <br />P.pproved for Conslruclion Date <br />RNAL INSPECTION Da�e <br />l�nn�oved as Constructed <br />rvcre�t PUBLIC WORKS DEPAHTMENT <br />� 3200 Cedar Street <br />Everetl, WA 98207 <br />Phone�. 259�8815 <br />�GI;tJCLNLEDGEMf�_NT OF CONDITION:i <br />Z <br />`� <br />The undersi(7ned o�vner/applicant hereby agrees to hold anJ save �i���* <br />less the Ciry of Everett Irom any and all claims foi damages, costs. <br />eapenses, or caases of action that may arise because ot installa`�on <br />and mainlenance of the imp�ovement or olher ripht-o�-waY ��� h" <br />applled lOr and furlhei a�lrees In iemmne same dPon not�ce !inin tt�•e <br />Cily 0nJ to rBp18Ce Public proocuy d�m�9rrl tlini�.�>y. <br />Signature of Applicanf �'��O <br />WORK AUTHORIZED BY THIS PER�11T MUST �E STARIED WITHit�d <br />100 DAYS OF DATE PEfiM1T IS ISSUED AND THEREAFTER IS TO <br />BE DIUGENTI.V PURSUED TO COMPLETION. THIS PERMIT MAV L'E <br />C�IJCCLL[:D L'.Y 1HG CIl Y U�'OIJ r1'JY STOPPP.G[ OF WORK OM TIiIS <br />FFt)JLCTOVGR?0 DAVS DUf'.ATION. <br />z <br />0 <br />.--� <br />c� <br />m <br />� T� <br />r-i �--I <br />N S <br />m <br />� � <br />mc <br />r <br />—I c <br />O � <br />fr� <br />S —1 <br />m <br />v z <br />c <br />�� <br />� � <br />< <br />'n <br />oD <br />-� �; <br />m �- <br />v <br />0 <br />o � <br />cv <br />3 �/ <br />m <br />_� <br />-i r <br />m <br />a <br />z <br />� <br />v <br />