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Date��Q"�Sa r�mu<vro�wsr��mn����-- <br /> Diap Den� � _ — <br /> Applicalion For _ _ <br /> PUBL.IC WORKS PERMIT �"°°`"'°"„°° S <br /> ro,.,���� <br /> Lvsenoni �cePnm S �O QO <br /> Dulancc ouo $ <br /> Print or Type Only <br /> ���ca-�c� T J3n.k.e[: H7�S v���u�v C—ve�EfF ln//3- FRzo 3 '�7_Uk�/ <br /> Ow�er Mailing Addr s City LP Phone <br /> � ...��_ -->ip _- — Phonc <br /> Applicant MaiGng Address ���Y <br /> , .II�� ' t ��c��I� <br /> Desci�beProposedWork n'�'� S,N��--`-�'_�—'�^"��"`��--— — <br /> La�-� <br /> W <br /> Pio�ect ACdress Id knowN _s-•� � S— u.�C�it/U AvE � <br /> � <br /> Atlach four 141 conies ol Plans for proposed work- Draw to scale and note Ihe lollowing as applicahle: � <br /> • Pi���erty Lines • Centerline ol slreel <br /> • O�."me and dimens�ons ot all existlns and • Indicate North <br /> p�cposed s!ruclures on ihe lol • Show any p�oposed 9iadmg changes <br /> • Ea�sung and proposed utdities • Show measuremenls M <br /> W <br /> 00 NOT WRITE BELO�N THIS LINE O � <br /> PERMIT CONDITIONS � <br /> t.All calls lor inspection shall he made 24 hrs.in ativance•phone 259•8�10. <br /> 2.All work shall be pedormed in accordance with this permit and current Ciy ol Everelt Design and Construc�ion <br /> Standards and Specilicalions. <br /> 3.Call Location Underground�ervice 48 hrs.belore you d�g TOLL FREE NIIMBER 1•800•424-555$. _u' <br /> i <br /> O <br /> � <br /> � <br /> O <br /> a <br /> ACKIJOWIEDG[MENT OF CONDITIONS <br /> Thr undersic�ned ownedanPhcant he�eUy agrees to hold and save harm- <br /> � Iess tl-�e City of Everett Irom any and all claims lor damages, cosls, <br /> expensr.s, or causes o� aclron Ihat may ari;e Uecause ol installation <br /> / / and �n�intenance ol lhe impiovement or othe� righl�obway use hereto <br /> apptied lor and lurlher agrees to remove same upon notice Irom the <br /> ApP«ve�'br C nnstru D te City and to replace puUlic pioperry damaged ihereby, <br /> G�� G_ 1 -�� ____�(�����, �o � �"� �� <br /> �a�e �.�� `-c" <br /> FINAL I PECTION Si9nature ol Applicant Date <br /> Approved as C�nstructed <br /> WORK AUTIiORIZED BY THIS PERMIT MUST BE STARTED WITHI <br /> everetl PUBLIC WORKS DEPARTMENT 180 DA1'S OF D�TE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CedarStreet BE DIUGEN7LY PURSUED 70 COMPLE710N. THIS PERMIT MAY B[ <br /> _vcrett.WA 98201 CANCELLED BY THE CITV UPON ANV STOPPAGE OF WORK ON THIS <br /> Phon�.259�8810 PROJECT OVER 90 D�YS DURATION. <br />