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Date �' "F �� Gubfc\Voiks Pa�mn v U✓ a� Z_' , <br /> eiae.oec�.: I�`:3�/ 2 /�?S <br /> Application For <br /> Pi.lBLIC WORF�S PER�I�II�' PubTa�ieePoe S �� . �� <br /> Less A00�Fee PaiC 5 " <br /> Balnnce Ouc S �' C� � <br /> Print or Type Only �!!18cI <br /> 7 <br /> �i�US No���eS T,.�, SLC- 5.f EUc-�,_c�� pu��• ;.Uhy E�."�Zc7 �ib1c�� 3SS-U4�ii_ -- <br /> Owner Mailing Address City Zip Phone <br /> j�mE /�S /�(3PVi= <br /> Applicant Mailing Address City Zip Phone z <br /> 0 <br /> � <br /> DescribeProPosedWork TfJSTr\�c ��5 � W�JC !t`U� RFtf ;b�'iU�=����,�� AT �C- 71 ��,:i�.�c�n1� e`55-i�'it` R <br /> � � <br /> - W � -� <br /> �, _ <br /> r ��� � o �, <br /> Prolect Address(it known) -� � � P�2�P�� t' L_�— �a �tin _ . � � p <br /> � m o <br /> Attach four(4)copies o� pla�s tor proposed w.�-k� 'r�w tu scala and note the foll6wing as applicable: �� � <br /> � � <br /> • Property Lines 9 Cenierline ol slreet /�A � 'm <br /> • Outline and dimensions ol all exi;Iin� and • Indiwte North V� C`'� Z <br /> proposed slrucWres on the l01 • SYow any proposed grading chanc�es m � <br /> • Exisling and proFosed utilities • S�iow measurements � .o < <br /> c <br /> s—�s <br /> DO NOT WRITE BELOW THIS LINE O � _' <br /> J (n <br /> PERMIT CONDITIONS � -n <br /> 1. All calls for mspection shall be made 24 nrs. in advanca- phone 259•881 5. � � � <br /> T � <br /> 2. All work sh311 be performed in accordance witL t iis per,nit and curreM City of Everett Design and Conslruction . <br /> --�m <br /> Standards and Specilicati�ns. m � <br /> 3. Call Location Underground Service 4B hrs. befo�e yoc diy.TOLL FREE NUMBER 1•800•424•5555. � � <br /> !. /�iYJu3/L �-vc:wTCr Ua(VC " JX `�b '�'/nc// /n � �"rCcU� � -OC- l�if <br /> � 'm <br /> Z �� <br /> J � <br /> � � T <br /> :D <br /> � � <br /> T <br /> � � <br /> .� <br /> � N <br /> O <br /> � <br /> n <br /> m <br /> .1CKN01NL[DGEMENT OF CONDITIONS <br /> The�ndersigned cLvner/applicant hereUy 29rees to held and save harm� <br /> I�ss the City of Everett irom any and all claims lor dama9es, costs. <br /> —, � enp�nses, or wuses of action that inay arise because of installalinn <br /> �—�9 ��� y-3U-�j anC ,naintenance ol ihe improvem=nl or olher righbof-v+ay use herr.to <br /> � � �- c�r.pl!.•d lo and turlher ac�rees to remove same upon notice Irom Uic <br /> roved tor Constiuctic^ Date ( ily nnd to�replace p blic prOperty,damaged lhereb�, <br /> � <br /> �� � < - � �-7�v� ��, , �<'°� � � , - <br /> FlNAL INSPECTION Dale . , %�� -- � Date <br /> Approved as Constructed Si�Lro of Applica t .� � <br /> WORK AUTHOR!ZED BY THIS PERMIT A4UST BE oIARTE� WITI-I�N <br /> evcrcl[ PUBLICI'JORKSDEPARTMEtJ,I� . �180 G\YS OF DATE PFRMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Streel 1 BE DILIGfN'LY PURSUED TO COMPLETION. THIS PEjiM111T MAY BE <br /> 6crctt,WA 98207 CANCELLED EiY THE GTY UPON ANV STOPPAGE OF WORK JN THIS <br /> Phone:259�8875 PROJECT OVER 90 DAYS �URATION. <br />