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� M <br />� <br />H <br />YH�L �+ <br />~ Z M <br />� H � <br />�°c y ro <br />� H � <br />� � � <br />t+y � <br />ri H <br />�•1 M <br />O N <br />� �y N <br />H O N <br />Gate `� �S/ <br />� Apphcalion f-or <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />nlP�l c�_�J�:� z-��� �3�k,•< <a,�; <br />_ � n�awna nc7tlress <br />� .._:c..i�,-����1�����.��� <br />� — <br />i'un'zwadeirte 5 <br />,o,a� F�� <br />� ., cr:.i n.�, rv��e 5 . - - - <br />,,, �,.� S_ — __-._ <br />t�i�1� �S �/ Ji( S — <br />;, Fno�,�� <br />SCiIY Z.P �� phOne, <br />qpplicant Mailing Addtess <br />�escri6e Proposed Work <br />Prolecl Addiess (il known) <br />A�tach lour (4) copies of plans fur proposed wo�k - Draw to scale and note Ihe foliowing as applicable: <br />• Property Lines • Centerline of stmet <br />• Indicate Nodh <br />• Outline and dimensions o� all ezisting and � Show any proposed r�ading changes <br />p.oposed structures on the Ioi • Show measurements <br />• Ezisting and proposed utildies <br />� PERMIT CONDITIONS <br />I1. All calls for inspection shall be mede 24 hrs. in advarce � phone 2S9•881 O. <br />'� � 2. All work shall be pedormed in accordance with Ihis permit and curren� City ol Everett Design and Construciion <br />� _� Standards and Specilications. <br />3. Call Localion Undergmund Service 48 hrs. hebre you dig. TOLL FR E E N U M B E R 1-SOO•424•5555. <br />,/'%il'�'C<C C/1���- /"t.»,l. fz �L�C>7 �'y.e 1( t.A�� <br />t <br />� ,,��,2:��1`nc :^�`=- <br />/ -:9->/ <br />W <br />H <br />M / <br />� <br />� <br />0 <br />a <br />I '=1�' ACKNOWLEDGLMHNT OF CONDITIONS <br />� _ The undersigned owneVapplman� hereby a9�ees to hold and save harm- <br />— Iess ihe Clty ol Evarett from any , nd aIl claims tor damages, costs. <br />CrpCn505, of CaU5e5 0l �CIi00 �h;lt mey ari5e beCau52 01 in5i.11l�iion <br />and mainlenance o( thn. improvemen� or oiher ri9h4of�way use hereto <br />applied lor and IurlLer agrees to removc same upo� nolice ��om tnr <br />Appmved for Construclion Da�e Cily and to replace public proverty damaged thereby. <br />FINAL INSPECTION Date <br />qpproved as Constructed <br />�,/ - ' PUBLIC WORKS DEPARTMENT <br />� 3200 CeOar Slreel <br />� EvnfeIl.WA9B201 <br />Phone- 259�BJ10 <br />Signalure ol Applicant --�-- <br />BORDAVSTOF DATC�- PERMIT ISEISSUED AND THEREAFT�C-(7 ISHTO <br />BE DILIGENTLY PUfiSUED 70 COMPLETION. THIS PERMIT MAY 8[ <br />CANCELLLD �� THE GTY UPON ANV STOPPAGE OF WORK ON THIS <br />PPOJEG7 OVf_R 90 �AYS DURATION. <br />