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t <br /> i �/ <br /> ; .. <br /> Date_U"5"S� 1 PuGI¢WorhaPo�mlt• <br /> AppGcallon For uwv.Doo� �_ Q"7�� - <br /> PUBLIC WORKS PERMIT `'°°.o,a��A`°° $ <br /> Lcaeappl fbenaiA � — <br /> Belence Due S <br /> Prin� or Type Only <br /> f>, . � �` o�.l T�,,,V • - , � � i e� 1/�d) 1) � �ni /���loP_ kd Ero.� H <br /> Owner Mailing ddress d Zip Phone <br /> � �-S C—,�l_f+L L1_LI_l e'+ �a � ,�� r��a,.,,�„ 7-�,�e Frria lf ��,J� 2 �3 5 3 - �L-7�� <br /> Applicanf � Malimg Addres� City Zip Phone <br /> DescnbeProposedWork /y Gf � f('if/� OJP� � D!'L�/N� /��(?�2✓` <br /> W <br /> Prolect Address(il known) �� � � <br /> Attach tour(4)copies ol planr.lor pioposed work- Draw to scale and nole Ihe lollowing as applicahle: � <br /> • Property Lmes • Centerline ol sireel � <br /> • Outline aod dimensions ol all ezisting and b Indicate N�rlh <br /> proposed structures on ihe lol • Show any proposed greding changes <br /> • E.isting and propo:;ed utilities • Show measurements � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1. All calls for inspection shall be made 24 hrs. in advance- phone 259�881 5. � <br /> 2. All work shall 6e pe�Wrmed in accordance with this pe�mit and current Ciry of Evr,retl Design and Construction <br /> Standards end Speciliations. <br /> 3. Call Location Undergmund Service 4B hrs. belore you nig.TOLL PREE IJUMBER 1•800•424•SS55. � <br /> O <br /> f�Ui.3GiC c<�o>�=,�Ss r�=�y�ii �-�'% !(�'�c���i!'.�i� �E,� � <br /> L9i�,�f/ �'�:��vfo/'O. �/� <br /> r�'�(.i�'✓ �/I <br /> ��riF-.�� O <br /> a <br /> ACIWO\NIEDGEMENT OF CONDITIONS <br /> Tt�e undersigned owneUanPlicant hereby agrees to hold and save hxrm- <br /> ---�--��--� I less the Ciry of Everett Irom any and all claims tor damages, costs. <br /> erpenses. or causes of action Ihat may arise because ot inslallalion <br /> and maintenance ot the imUrovemenl or „Iher ri�ht-of�way use hereto <br /> — apphed loi and lurther aaiees to remove sam� u�on �icl��ce Ircm Ihe <br /> �pproved for ConSiruti{on Dale Cilv and to rr�place public pioperty damag�d ihcreby. <br /> FINAL INSPECTION Date _— <br /> Approved as Constructed S�pnalure ol�pphcant Date <br /> WOHK AUTHORIZ[D BY THIS PERMIT MUST B[ STARTED WITHIN <br /> rvrretl PUBUC WORKS DEPARTMGNT 180 DAVS OF DATE PERMIT IS ISSUED AND TF1ER[AFTER IS TO <br /> � 3200 Cedar Sireet B[ DILIGENTLY PURSUED TO COMPLETION. THIS P[RMIT MAY BE <br /> Evere�t.WA 98201 C�NC[L'_i=D BY THF CITY UPON ANY STOPPA�E OF\VORK ON iH15 <br /> Phone: 259-8875 PROJC('T OVLI�3n UI�YS DUf7AT�ON. <br />