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/ i <br /> Dale�� .l 4�- 1?-Z9` S P��,�,���o,����(��m,�. �9�-/4S� <br /> x B�apoeo�.• M���j, ` � <br /> p. Application For <br /> w <br /> PU�LlC WOR�CS PERMIT PueTotalfeeFee $ <br /> p Less Pppl Fea Na�O $ <br /> O <br /> BaianceUue S z�� <br /> Print �r 7ype Onlya $ g <br /> :� � 3w I <br /> RI I , � / p ^ <br /> nD� L� fT—� ��(`CTO(� I0 ?7 � `O�dn �✓PlA �� r� r��7c�—�5��_ <br /> Owner � � N 4 MaiNng Address City Zip Phone I <br /> � <br /> M Y O [._.� ' <br /> O <br /> qpplicant Mailing Address Ciry Zip Phone ,I <br /> Describe Proposed Work _}� A ��� ° �1�N� ��J '��� � '"8S � � —�S �� <br /> li <br /> -- � Ili <br /> Prolec�Address lil known) I `z'3 �l Q.�q 1 NiA aaYC � � <br /> Atlach lour(4)cop�es ol plans lor propesed work- Draw to scaln and note the lollow�ny as applicable: �� i <br /> • ProCe�N Lines • Cemerli.�e ol,treet ♦A <br /> • Outline and dimensions ol all existing and • Indicate horih V� I <br /> proposed siructurr;s on ihe lol • Show�ny pic,^^ced grading ch;,nges <br /> • Eaisting and proposed u�ilities • ;- 'ow measurements � � <br /> DO NOT WRITE BELOW 11.15 LWE I <br /> PERMIT CONDITIONS O li <br /> 1.All calls for inspection shall be made 24 hrs.in advance-phone l59•8810. � �i <br /> 2.All work shall be perfonned in accordance with this permit and r.�•rent City of Evereit De,ign and Consiruction <br /> Standards and Specilicatiuns. � <br /> 3.Call Location l'nd?rground Service 48 hrs.be�ore you dig.TOLL FREE NUMBER 1•S00•424•5555. � , <br /> 5! �l c.�e�� �'Jvr�a�.z`cm� �2'`v 6� ...,:�z` /�t'�/� ���rova,,G O <br /> ,t, y�.� ��` .�� -5�.�,., li.��y _�,a.�,� �, <br /> .c,,.� ,�ti�z ��. �� <br /> S. .5�'-�-! .�'f-� ���.�-��,.�- .� ,�� �,�.�, �ll <br /> �, l]�Y/J G/y/ S�r'ec:7`S C��cir� 47� 4�� �in�BS . � <br /> a <br /> ACKNOWLEDGLM[NT OF CONf11TION5 <br /> �� Thn undersignetl ownedapplicrmt hereby agrees to hold and save harm� <br /> less tlie City ol Everetl Irom any antl all claims for damages, cosis, <br /> �� ezper,es, or causes of aclion that may arise because of installation <br /> �/I/� �V_� �^ .�p,� and maintenance ol the improvement or olher right-obway use hereto <br /> Y Y � F-'� O �pplied lor and luriher agrees lo remove same upon notice irom ihe <br /> qpproved lor Cons ction ���� City and tt�eplace public property dainaged the�eby. <br /> � � r�- <br /> ��%"� �-- �-���'- yi ���,� , <br /> Date , s- 7� �/ . <br /> FINAL INS�' CTION � � <br /> Approved as Construcled Si nat re of Appl7ca � Dale <br /> W R AUTHORIZED 2Y THIS PERMIT MUST BE STARTED JJITHIN �� <br /> everelt PUBUGWORKSDEPARTMENT 7g0 AYS OF DATE FERMIT IS ISSUED AND THEREAFTER IS TO � <br /> � 3200 Cedar:ireet BE OII.IGENTLY PUFSUED TO COMPLETION. THIS PERMIT MAY BE ' <br /> EvercU,WA90201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259-8810 PROJECT OVER 90 DAYS DURATION. <br /> I <br />