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� _L <br /> .��+2 i <br /> I <br /> F • J, _ _ �p Punec WOr�f Permn� �— / _ I <br /> Date�� � � �eiep oeoi •� -'L-�-1f�Y(�— <br /> i �pplication For __ <br /> PUBLIC WORKS PERMIT °„"r�;�����"' S — <br /> � � �ms voni fc�Pa�o 5 <br /> A�� oa�:�ceo�� S <br /> � � Print or Type Only <br /> C H <br /> Hy� ' ,. , ,, �,� 2ro�� ti��,rk�� ,� �vr 9fr?ol L�Z -�3� <br /> H ��"'� -�� MadingAdd�ess City Phonc <br /> k y� i Owncr ^ 20I j n � �_— �� <br /> �i1 H'C �^ � ��)��Ilr � ���� i�I1� / ) �U L U � CiIY r.iP __-. Phone <br /> y~ Ma�lin9 Nddress <br /> H � APPlicant <br /> � �� ,, 1 1� c�r�c m , .��l� ha a-h — ��'�,s-�' <br /> O H� I DeSCnUe P�opoSed Work _�l.l.����� <br /> � �8 <br /> n� � <br /> r y� �'', W <br /> HH ��y N I <br /> p �y I Pm�ect.�ddress hl knownl <br /> � <br /> � �� i Altarh tour 1�)coaies ef plans lor p��Posed woik� Draw lo scale and note the lollowing as applicable: � <br /> • Prope�ly LineS • Cen�erlme of Street <br /> x H ti i • Outline antl dimensions ol all existing and • Indicate Worth <br /> y p y • Show any pioposed 9rad�n9 changes <br /> '� proposed slmciures on Ihe lol � S��ow mea5uremenis M <br /> � • E.isting and p�oposed utilities W <br /> . DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS ^ <br /> I , 1.HII calls lor inspection shall be matle 24 hrs.in advance-phone 259•8810. <br /> 2.All work shall be pedormed in acwrdance with ihis permit and wrrent City ol Everelt Design and Conslruclion ♦ <br /> I �' � Standards and Specilicalions. � <br /> �,�� � 3.Call Location Undergmund Service 48 hrs.belore you dig.TOLI FREE NUMBER 1•800'424'5555. <br /> .�. .� �I � ,,� � . � � <br /> � �. ; ` i ��� ,.. , :'. �., ' , � <br /> �� �' , . l,.r . . . � � � <br /> / � ,_�/�y <br /> f�/:F" : <br /> i i Y�,• <br /> � � �^•_C � <br /> O <br /> � <br /> _�-� � a <br /> ` � ' I Ai.KNOWLEDGGMENTOFCONDITIONS - <br /> I , <br /> The undersi9ned owner/apP��cant hereby agiees�o hold ai d sace harm- <br /> '-'�' less Ihe Ctly o� Everetl trom any and all claims for dan��a9es. cosis. <br /> exnenses. oi causes o� action ihat mny arise hecause ni ins�allalion <br /> and maintenance nf ihe imp�ovement or olher ri9M�obway .ise hereto <br /> �pplied lar antl Imihu a9ree5 Io �emove same uUon i:cbce ��om ihe <br /> '• " � Appioved lor Conslruclion Date Cdy and Io rep�3ce public p�oPerty dama9ed Ihereby. <br /> I <br /> � FINAL INSPECTION Date Date , <br /> Siy���im2 0l AppliCant <br /> qppmved as ConsUucted � <br /> WORK AUTHORIZED 0Y THIS PERMIT MUST BE STARTED WITH <br /> '^�,�„�„❑ I PUOLICWORKSDEPARTMENT 180 DAYS OF OATE PERMIT IS ISSUED ANO 7HEREAFTER IS T� '� <br /> II � 3200CetlarSlreet BE DILIGENTLY PURSUED 70 COMPLETION. THIS PERMIT IdAY BE � <br /> Evr.reit,WA 98201 CANCPLLED HY THE f,ITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259-f3810 PROJEGT OV6R 90 D..YS CIURATION <br /> I <br />