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�/ / �)G� y <br />Date�Z <br />M <br />� PU�IC <br />X <br />Print or Type Only� <br />� <br />�s <br />� D�'�� C,��.;,��� �jl `, <br />�l���` U <br />Application For <br />WORKS PERIVi!!1'"� 1�' ��90 <br />� 47 <br />� N.» <br />0•�19��i'cv- � <br />�� Mading Address <br />d �0 <br />�33-6 �v�-v«�k� <br />Mailinq Address <br />...� . ............................�.......� <br />.......... . <br />CITY OF [VERETT. <br />Public Works DepL <br />c'u <br />PWL[\Vo��sPermit• �0 — �� �• <br />B�dB Deot • <br />PuOLc Wo�la �ec s <br />Tpldl fPP <br />lesf AODI FPe Paia 5 <br />Balance �ue $ � <br />DD?. -��'� - 5�0 000 -/8- B3 i <br />wn 9F�e3 �s'� <br />Zip Phone <br />-Q4 <br />Descr�be Proposed Work �/� �r D<C"A�� L�_ f1e�� G� �% � f�1 �:-�'�,[' 'nl!'i. U_�. FZ+�II� 'K� IZ <br />i <br />� �2aiJb �G,�/�l..r��, S/OPz tr �.,ar�o A�a.�x� �N r.��trotz �' i.�rsT4tl <br />� / � � C R �lb ✓a 7�u 2�5� , C <br />Prole�l Address (il known) ��� C�� —/I /d �r) Y' C cJPCP !7 LUf� <br />Attach lour (4) copies ol plans br proposed woik � Oraw to scale antl note ihe following as applicable: <br />J Property Lines <br />• Outline and dimensions of all existing and <br />proposad slruclures on Ihe lot <br />• Eaisting and proUosed utilities <br />soo <br />• Cen�erline ol Slreet <br />• Intlicate North <br />• Show any proposed grading changes <br />• Stow measuremems <br />(AL�'L4C'y <br />{,<<�� <br />P�.: � ;�,.,��y <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259•8810. <br />2. All work shall be pedormed in accordance with this permil and current City cl Evemtl Design and Conslruction <br />Standards and Specifications. <br />3. Call Location Undei�round Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424•E+555. <br />7 ��j,S �,�'�'mi �iJ �r' 7'ii� G'� (�7C ni�..�/�J�c�Je�Y f�.�il�f/ <br />Gr,d c�o�1 hOl�9ia�L' Q[-Y�tia;v�a�.on Y t�l� o�i �i�B <br />%JIB"���L�ri.'�� P/'c�C'/'�j/. <br />�r. /��a��7` J'�uz� S�cy�eS' �'-��{ii �rusS oi- nf�i�r �/��afufion, <br />�. Zns�nlC di�f2✓ciC �� /���C /i�l�f.f' inY<<, <br />d�sc/c.�c oi�fo �����y/;Gcrs p,���,zrty� <br />�epu�•fi,��•�f inS�ac�or reya�v�i.�f ��s <br />everelt PUBLIGWORKSDEPARTMENT <br />� 3200 Cetlar Sireet <br />Everett. WA 98201 <br />Phone:259�6810 <br />— c% rat �/,'r,�c� <br />Se� j>vfiG'< <<tr,fs <br />ACKNOWLEDGEMFNT OF CONDITIONS <br />W <br />� <br />� <br />N <br />� <br />� <br />� <br />Y/ <br />O <br />a <br />-i he undersignetl owneUapplicant heieby ac�rees lo ho�d and savc harm- <br />less ihe City ol Everett Irom any and all claims lor damages. costs. <br />expenses, or causes ol action that may aiise because ol inslallation <br />and mainlenance of Ihe improvement or o�her right-of-way use hereto <br />applied for and further :,giees to remove same upon notice hom Ihe <br />City and to replace public property damaged thereby. <br />�ZJ� Q �-n � �v /G �/- �� <br />Siqna�ure uf App cant Date <br />WURK A�JTHORIZED BV THIS PERMIT MUST BE STARTED WITHIN <br />180 OAYS OF DATE PERMIT IS ISSUED AI�D TIIEREAFT[R IS TO <br />BE DILIGENTLY PUFSUED TO COMPL ETION. THIS PERId1T MAV BE <br />CANCELLED BY THE CITY UPON ANV STOPPAGE OF WORK ON THIS <br />PROJfCT OVER 90 DAYS DUflATION. <br />