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Date <br />AppliCatipn For <br />PUBLIC WORKS PERMIT <br />Print or Type Oniy <br />� <br />'�I 3 i'i 5 . � <br />Mailing Address <br />City <br />PuGM1c Woiks Permil s <br />(J J — i'�L/ ) <br />Biap oen�-+ <br />PubLc Warks Feo � <br />Toial Foe <br />Les5A00� Fee Pald S <br />5 �o.na <br />Balance Due <br />%�-3 `'3 <br />3' Z 0-'� �.Z 5 2 2 5/ <br />Phone <br />.S al.o�F <br />Applicant Mailing Address City Zip Phone <br />� <br />Describe Proposeu Work i/Y S/ � C/ /�� � L!i C C/d C%"C— � LG ��^/ ���: GC� �l�/ <br />Prolec� Address (if knawn) <br />4ltach four (4) coUies �� ^lans lor proposed work - Draw to scale and note the lollowing as applicable: <br />• Property Lines <br />• Outline and dimensions ol all existinp and <br />proposed structures un Ihe lot <br />• Exisling and proposed utilities <br />NOT <br />PERMIT CONDITION� <br />• Centerline ot sireet <br />• Indica�e NOr�h <br />• Show any proposed �rading changes <br />• Show measuremenis <br />1. All calls lor inspection shall be made 24 hrs. in advance - phone 259-88� 5. <br />2. All work shall 6e performed in accordance with this permit and current City of Everelt Design and Construction <br />Standards and Specilicalions. <br />3. Call Localion Underground Service 48 hrs. 6elore you dig. TOLL FREE NUMBER 1-800•424•5555. <br />�il. fi�'OLiCGivT T f1 TiL1 i�J SEcJEi.= AGTe=/_'G iirN <br />��. 'U.�,�/ ,[%/JlJ : f�Orif%.�' DOI.v�'✓- Sf'DUTS �NdilEir"G' <br />O.0 v.� fv��c�G <br />,� ; . �i :..,� �,,�� <br />�iL <br />��z�To S��sGs���,� , <br />.c>o�- !'.•--: ��,: ---r_ , . <br />L1CCC� T�p•!/Gaie.r.J ro Usr. <br />�./���n��- �� ' ��� <br />qpproved lor Constru ion - / Date <br />�//�///l�l��� �U /�' �1� <br />-�-F7(�L—IN�SPECTION Date <br />qppreved as Consiructed <br />evcre�t PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everelt. WA 98201 <br />Phone:259-8815 <br />%1e'� �,_�'�.='�> <br />ACKNOVJLEDG[M[NT OF CONDITIONS <br />W <br />H <br />0 <br />N <br />� <br />O <br />♦rA <br />V♦ <br />� <br />a <br />The undersi�ned owner/applicant hereby ac�rees to hold and save harm- <br />less Ihe Ciry ol Everetl I�om any and all claims for damages, costa, <br />expenses, or caeses of action �hat may arise because ot inst�llation <br />and maiMenance of ihe improvement or other righPof�way use herelo <br />applied lor and lurther ayrees to remove same upon notice Irom �he <br />Gity and to replace public property damaged thereby. <br />���.,�1 �C'�Z� i/.' 7/,�s <br />Sig�J�tGre of ApUlicanl ' Date <br />WORK AUTHOfi12ED BY THIS PERMIT MUST BE STARTFD WITHIN <br />1B0 DAYS OF DATE PERtAIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PER�dIT MAV �f_ <br />CANCELLED E THE CITY UPON ANY STOPPAGE OF WOHK ON THIS <br />PROJECT OVE�9 90 DAYS DURATION. <br />