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�j �O <br /> _1� -V S Fuoi�c worxn Permil� <br /> Date � � BiE9 Oepl + <br /> App��cation For <br /> PUBLIC WORKS PERMIT P���'�WO«aFee s ,_.,.__ <br /> TOLI Fee <br /> lesf PDG�-Fee Pa�tl S �O� <br /> 9abnte Oue <br /> Print or Type Only <br /> 1 ` ,?d C 7 asz- � o3 � <br /> Y"IO.nYe ��c"�a c\S `�O� U��•N � S Jf. Phone <br /> Owner Mailing Address <br /> CiIY Zip <br /> � <br /> ZiP Phone n <br /> Mailing Adtlress City � <br /> qpplicant •• <br /> %'� �o...l ei a� P l nct ��:, s�-�,'n 1 c. er <br /> Describe Proposed Work ra� �- S —�N 1 y ] � <br /> N�-R. -c U ro C-f• " <br /> H �. <br /> W y � <br /> H �� <br /> G,Olo V Er,� ,�inr E Qt. -- � � � <br /> Pmject Address(if known) � <br /> Attach lour(4):.opies ot plans for proposed work- Draw to scale and note�Ceole�ine ol stpee� able: � � � <br /> • Properry Lines • Indiwte North � <br /> • Outline and dimensions r�i all existing and � ghow any pmposed grading changes <br /> proposeA slruclures on •he lot M � <br /> • Show measuremenis W � z <br /> • Existing and proposed urlities y <br /> � x <br /> DO NOT WRITE BELOW TNIS LINE y � <br /> K � <br /> PERMIT CONDITIONS � 0 <br /> � <br /> 1. All calls for insC�ction shall be made 2A hrs. in advance•phone 259•88 . � <br /> 2, All work shall be performed in accordance with ihis permit and current City ot Everelt Design and Construction <br /> Slandards and Specitications. � F" <br /> 3. Call Location Underground Service 48 hrs.belore you dig.TOIL FREE NUMBER 1•d00•424•5555. N <br /> Q � � <br /> � � <br /> N � <br /> O � <br /> a N <br /> � <br /> H <br /> � <br /> qf;KNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owneUappliwnt hereby agrees to hold and save harm� <br /> less the City ol Everelt Irom any and all claims for damages, cosls. <br /> p�,�7ECOfiNN/S expenses, or causes of aclion thal may arise because ol inslallation <br /> /_ ���y // s and maintenance ol the improvement or other right-ol-way use herelo <br /> , � applied 1or and furiher agrees to remove same upon notice irom the <br /> Date City and to replace public prope/tY�sged thereby. <br /> Approved lOr onsiruction , � <br /> ���7������r .� ,/`—/ � f��� <br /> Date Date <br /> p� ECTION Signature of ApPlicant <br /> qppmved ae Constructed WORK AUTHOHIZED BY THIS PERMIT MUST BH STARTED WITHIN <br /> Oeverett PUBLIC WORKS DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> 3:200 Cedar Sireet BE DIUGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY 8[ <br /> Everell.WA 98201 CANCELLED BV 7HE CITV UPON ANY STOPPAGE OF WORK ON THIS <br /> Phonc: 259-8815 PROJECT OV[H 90 DAYS DURATION. <br />