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Date '��'�' <br />� , � <br />Application For <br />PUBLIC WORKS <br />Print or Type Only <br />-- J—'—" I --� — <br />Applir.aM <br />f`ec;cribe Pro�oseJ Work <br />Project addr.�se (il knawn) <br />PERM�T <br />City <br />ng Address <br />_ y� v,��, s� <br />z�� <br />Gu���c IYO�FS Vmnil ��_/;`� � ^ /� � <br />eiag. Dco� � � —��/ -- <br />PUEIic \Yorka Feo $ <br />Totnl F¢e <br />Lesa Rpol. Fea Pe�A g <br />'^ �JO <br />Balance Oue � �"� <br />A�tach lour (4) copies ol plans lor proposed woik - Dr:,: �- ;w'r. �nd note Ihe lollowing zs apP��cable: <br />• Froperly Lines • Centerline ot slreel <br />• Ou�line and dimensions ot all existing and • Indicate North <br />propusetl siructures on the lol • Show any proposed grading changes <br />• Existing and proposed utilities • Show measuremenls <br />3G� 3 <br />Phone <br />PERMIT CONDITIONS <br />1. All calls for inspeclion shall be made 24 hrs. in advance � phone 259•88� 5. <br />2. All work shall be pe�lormed in accordance with Ihis permit and current Ciry ol [��erelt Design and Consu ua�,on <br />Standards and Specilications <br />3. Call Location Underground Service 4B hrs. belore you di�. TOLL FREE NUMBFR 1•800•424-5555. <br />4. ANY GRADING DONR ON THIS LOT SHALL BE DONE SO AS NOT TO IMPACT THE <br />SURROUNDING LOTS WITH RAZN.'v7ATER RUNOFF, <br />5. ANY CURB & GUTTER OR SIDE�9ALK DAMAGED DURING CUNSTRUCTION SHALL BE <br />REPLACED BY THE APPLICANT. <br />y v,�y�,��c <br />E. ROOFTOP D0�4NSPOUTS SHI�LL BE TIGHT-L.LNEll TO `PHS--PE7BL-IC-DRi�INAGE-SYS7`EPi. <br />�-Sf7I LS-ft EPORT-FOR�'TH�I S-i�(�T-IS-RBQU I RF. D-B E['ORE-CONC RETC-POR-�H E <br />F6[iNIIATIU[�75-POUR£D � <br />_)�� %� % ��'z 3���86 <br />� / .!'�%., � <br />Approvetl lo Cons ructi n Date <br />�<� � � <br />FINAL INSPECTION Dale I <br />Approved as Conslructed <br />everett PUBLIC WORKS DEPARTM1tENT <br />� 3200 Cedar Street <br />[verelt. WA 98201 <br />r Phonc:259-BC15 <br />W <br />�" <br />� <br />� <br />� <br />�J <br />ACKNOWLF . � �ENT G� COIJDITIOhS <br />Th�� .� .Aersigned ov.'ier/aF �� � nt hereby agrees to hold and save hann- <br />lesa � he Cily .,I Ev:retl tri . any and all claims lor damages, cosls. <br />expen,ee, or cacset. of action that may arise because ol installeUc❑ <br />and maintenance o' lhe improvement or o�her �ighl-obway use hereto <br />applied lor and lurlher agrees lo remove same upon notice Irom lhe <br />City and to lar�. pub � pr perty damageA thereby�. <br />��1 � �6. <br />Sign �ure ol Applicant D e <br />WORK AUTHORI2ED EY THIS PERMIT iUST BE STARTED ITHIN <br />180 DAYS OF DATE PERAIIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTIY PURSUED TJ COMPLETION. THIS PERMIT MAY BE <br />CANC[LLEC1 �Y THE CiT'/ UPON ANY STOPPAGE OF WORK ON iHIS <br />PNOJECT O'dtR 90 DAYS DURATION. <br />