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Date "�e�z� i,�o���w<�„N��m,i. �'f .3y5 <br /> Application For eiac ovo�.• __ <br /> PUBLIC W4RKS PERMlT P����cWorkaFae <br /> .e�.�F�< s <br /> tess doo�Poe Psia S <br /> Print or Type Only ea.a��e c�a S �L�./��� _ <br /> �a�9d'" <br /> -, <br /> �. <br /> �� il� "c:' i1�r'�,i<: � '?i �/ L i v'r, � /l'���f� �.�. � (>.�-F-�f �}.',� .'- <br /> Gwner � Mailirg Address Cily Zi Phone <br /> 3���-v7v� <br /> ���["1 /-r� �l°ji'.a � rcr'��Tr'�i�j��ic� . -Tii.�� ��i'�l-� ,'r��� l ' i��oA'� 'l�r`r'n / '�� <br /> Appli�nM Mailin9 Add.ass Tty Zip y�-p e <br /> / J , � � , r <br /> Describe Proposed Work �(S._LC('���1 I I Vc�� t. ��u +�-� LI�D Tc� <-�4/'dG - <br /> Prole[t Atldress lil known) ',/C'<� �_�; F��, � JY �l��r"d' ��✓ I L:.l, . � <br /> Attach Iour(4) copies ol plans for proposed work- Draw�o scale and note Ihe following as applicable: � <br /> • Property Lines • Centerline of street //� <br /> • Outline and dimensions n�all exisling and • Indicale North V, <br /> proposed structures on ihe lot • Show any proposed yradmri chanqes <br /> n Eaisting and proposed utiP,ties • Show measuremenfs � <br /> DO NOT WRITE BEIOW THIS LINE O <br /> PERMITCONDITIONS <br /> 1. All calls lor inspection shall be mace 24 hrs. in advance- phone 259•881 5. � <br /> 2 All woik shall be perlormed in accordance with this permit and current City ol Evercit Desi9n and Construc!�nn <br /> Standards and Specilicalions. z <br /> 3. Call Location Undergwund Service 48 hrs. 6efore you dig.TOLL FREE NUMBER 1-800•424•5555. � L <br /> r <br /> y �i4LL I�i�i��fT!'/: D''Efo.c'E ST.a.�:.-/h�'Lr D,t'.o'C�s�i� O r; <br /> /t/O�f�,C To LLsCvss /�9ETilOs�� Fn.2 !'ONT,t•v�i.L'C.- <br /> /�DTr Ni/!a G 'STi,>E� �k'<�.vL'/1 C c� P��C l��F/17. � - <br /> C;a�_n � �r�� �/En l � . <br /> � � � � <br /> � � � <br /> �� : <br /> � <br /> Q.. � ;� <br /> :; ; <br /> r : <br /> �� ACKNOWLEDGEWENT OF CONDITIONS � <br /> :� / <br /> �__ The undersigned owner/apolicanl hereby aQrees lo holA and save harm- `; <br /> Iess ihe City of EvereU Irom any and all claims for damages, costs, •� , <br /> ezpenses, or causes of ac:ion that may arise because ol installation — <br /> d— /Z G 9./ and mainlenance ol Ihe imProvemeN or other �ighbot�way use hereto _ � <br /> «'y�r �� applied fo� an� turther agrues to remove same upon no�ice Irom Ihe - <br /> auprmetl tor Consiru ion ate City andao replace public f-��operty d:�maged thereby. � <br /> ��.�'l�- �- -�r .p ¢� ;` <br /> NA INSPECTION pa�e .�?ltit � .C7/Joe'r�'� ��-� O'- O y `-� <br /> Approved as Constructed Si�nature ol Applicant Date �' <br /> evereu PUBUC WORKS DEPARTMENT WORK AUTHORIZED BY THIS PERMIT MUiT BE STARTED WITHIN <br /> 3200 Crdar Street 180 DAY6 OF DATE PER'd1T IS ISSUED AND THEREAFTER I� TO <br /> � EveretC WA 98201 BE DILIGENTLY PURSUED TO CO�dPLE710N. THIS PERMIT MAV E±�' <br /> Phone� 'S9-8E15 CANGEL'_FD BY 7H[CITV UF•ON AIJV STOPPAGE OP WO�K ON Ti11� <br /> PiiO '�G� p�[ii�0 ib�..i5 CliFr:iIGN <br />