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� � � <br /> �_� ,,,,.��,v,�,,..�„�„��� . --�9�)_- <br /> Da�e_?_ _ <br /> i�.i,r� orn� . __--_—___- _ <br /> APnIiC.ltion Fo�p� <br /> PUBLIC WORK�QPERMIT ''°`�°`"'°„°`Ce - <br /> r�„���� s--— <br /> p I r.s ep„i 1 n,.na,�f 5 <br /> � 'I����`- <br /> Print or Type Only <br /> _ �5 a r,,..,. �.r���.. S -- <br /> � ws <br /> �_ m .n a <br /> �v��Ps:f�d J.,,.� vs /�. / ,5��? _Cv�a..i�C' /�'�,ta � 3.is` r2s� <br /> Owner Madiny AAE�ic3s�p "� City 7_ip Phone <br /> � p H W <br /> �0�1£� � � ���,�{�— 5'P'aoc 35S /1-�3 <br /> ApPlicant Mail�n9 AAdn�ss GIY Z�p Phonc <br /> DescriUc P�oposed 1NorM �� ---1Y-�«f�-� <br /> - W <br /> P�olect AAdress 1�1 knownl ��^�"� ���� � <br /> Atlach lom ial cop�es ol pinns lor pwposed wo�k- D�aw to�note the following as aPPlicablr� � <br /> • Property Lines • Cenlerlme ol street � <br /> • Outl�ne and dimensions of all exisl�ng and • Ind�cate North <br /> P�oposed strcctures o�Ihe lol • Show any proposeA giadmg changes <br /> • Ex�st�ng and proposed utddies • Show measurements � <br /> DO NOT\NRITE BELOW THIS LINE O <br /> P'cRM1T COND�TIONS <br /> 1.ql1 calls lor inspection shall be made 24 hrs.in advance-phone 2b9•8810. � <br /> 2.All work shall be pedormed in acCordance with this permit and current City ol Everetl Design and Cocstruction <br /> Standards and Specilications. <br /> 3.Call Location Underground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1-800•424-5555. � <br /> ,.� �?� l/„��.,,���/rs � <br /> � <br /> � <br /> 0 <br /> a <br /> ncr.Now�enc�is�NT oF co��oirioNs <br /> The unde�si9��ed ownei/upphcanl hcieby agrees�o holo and savi�harm- <br /> — Iess the Cily ol Evc�ett ir�m any and all claims for damages, cosls. <br /> j�j eapenses, o� causes ol aeuon Ihat may arise because of msialiation <br /> and maintenance of lhe improvement or olher ri9hbof-way use hereto <br /> apnhed lor and Iwther a9rees to remove same upon notice irom the <br /> Ap vr_tl lof on lion ' Date City an o replace public prope�ty damaged thereby. <br /> � �-bl�_1�--- f7` 1�Cl�� / <br /> .._-�_ . � � 3//PS _ <br /> F�NAL INSPECTION D3tc q �' <br /> �PProved as Constructed <br /> iqnalw . ol APP!�Canl � � ale <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STAFTflD WITHIN <br /> rvcrrtt PUBLICWORKSDEPAPTMENT 1p0 DAYS OF DATE P[RMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CetlarSireet BE DILIGGNTLY PURSUED TO COMPLETION. THIS PERMIT IdAV BE <br /> Evr.relt,WA 99201 C�NCLLLED BY TH[CITY UPON 1NY STOPPAGE OF WORK ON THIS <br /> Phone�.259�8810 PROJECT OV[R 90 DAVS DURATION <br />