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�� � � � Pupl¢WoikS Pelmil• �� <br /> Date_L�_,_� � <br /> �noi�caiwn ru� nio9 0�0� •� � <br /> PUBLIC WORKS PERMIT �°°'�°W°",`°° <br /> miai Fea �— <br /> i�rs�nnn�.Fco Pe�a 5 <br /> en�n�ce ooc <br /> S �'y� �-� <br /> Print or Type Only <br /> ��L1�/l�{�SHiP �3 � ID>�.St-�L ��J�'�i" �ISZD� ��37-��9 <br /> Owner Mailing Address City Zip Phone <br /> ���1Y11� - <br /> Applicani Mailing Addiess City Zip Phone <br /> Describe Proposed Work � � ��.LL�— <br /> W <br /> Prolect Address pl known) ��C� �� - U�L A�✓v AI�E � <br /> Allach lour(41 copies ol plans br proposed work� Draw to scale and note�he lollowin�as applicable: � <br /> • Properry Lines • Centerline ol street � <br /> • OuUine and dimensions of all ezisting and • InAicate Nnrih <br /> proposed structures on the bt • Show any proposed c�rading changee <br /> • Existing and pioposed ulilities • Show c�zasurements M <br /> W <br /> DO NOT Wf71TE B[LOW THIS LINE O <br /> PERMIT CONDITIONS <br /> t. All calls for inspection shall ue made 24 hrs. in advance-phone 259-881 5. � <br /> 2. All work shall be perlormed in acr,ordance with this permit and current City ol Everelt Design und Construction <br /> � Standards and Specilications. <br /> 3. Call Localion Underground Service 4A hrs. belore you diq.TOLL FREE NUMBER �•800-424-55$5. � <br /> O <br /> � <br /> � <br /> O <br /> a <br /> ACI<NOWLEDGEMENT OF CONDITIONS <br /> � ��(,; The undersigced owner/applicant hereW-egrees to hold and save harm- <br /> --- -- Iess Ihe City ol Everett Irom any an� all claims for damayes, costs, <br /> expensos, or causes of action Ihat may arise because of instal�ation <br /> -- ' �� ,4-� and maintenance of the improvement or other right�ol-way use herelo <br /> �� -� -�� ���� � " applied for and further agrees to remove same upon notice irom the <br /> Apprwed lor Co� Dale Ci�Y and to rePlace Public ProPerlY dama9ed therebY. <br /> /.1• 2 'F� j/���'L f%�/Z�(�- �Gl'k� ��. �� <br /> FI L INSPECTION Data F o <br /> Approved as Constructed Signature ol ApPlican� � Date <br /> WORK AUTHORIZED BY THIS PERMIT MUST B[ STARTED WITHIN <br /> ��� PUBLIC WORKS UEPARTMENT 7g0 DAYS OF DATE PERMI� IS ISSUED AND THEREAFTER IS TO <br /> 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAV BE <br /> Everelt,WA 98201 CANCELLED BY THE GTY UPON ANY STOPPAGE OF WORK ON THIS <br /> Nhone: 259�8815 pROJ[CT OV[R 90 DAYS DURATION. <br /> � <br />