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�<r,/��� ApplicationFor ___- _ J_— — <br /> PUBLIC WORKS PERMIT o��e __lo�s��� <br /> PU�UC WORKS DEPARTh1ENT Public Works Pertnit u _//�JZ�_ _ <br /> 3200 Cedar Stree� — <br /> Evmen.WA 98201 259-H810 <br /> Building Permit q_ Sfi%15 <br /> 1YPE OR PRWT ONLY Public Vlorkr Fee 5 �S� <br /> _ BERGSTROM VIRGIVIA1505 PIUKILTEO LN MUKii.'i`'0 98275 '3� <br /> Owner Maihng Address City Zip Phonc <br /> _L�iFE AAfORE CONTACT LARRY STAVE 334-5018 Y.309 <br /> �ppLr.ant MailingAddress City Zip Phone <br /> Describe Proposed Work _ PL4CE GSPRESSO STANll <br /> ------- -- - W <br /> _ I-- <br /> - <br /> PROJECT ADDRESS (if known) _ 2726 RUCKER AVE � <br /> Auach}our(4)copies ot plans for proposetl wo�k-Draw to scale ard noie it,e following il applicable: � <br /> •Pmperty Lines •Outline and dimensions of all eaisling and propos:d simctures on Ihe lot •Existing and proposed utilities ,� O <br /> •Centedine ol sheet •Indicate North •Show any p;oposed qmtling changes •Show measurements � <br /> CO NOT 1JRITE E3E�OW THIS LINE <br /> PERMIT CONpITIONS: � <br /> 1. All calls for inspection shall L�e made 24 hours in advance - phone 259-8810. <br /> 2. All work shall be performed in accordance with th�s permit and current City of Everett Design and O <br /> Construction Standards and Specifications. <br /> 3. Call Location Underground Seivice dF3 hrs. before you dig. TOLL FREE NUMBER 1-800-424-5555. � <br /> �/ <br /> O <br /> la <br /> ACKNOWLE�GFMENT OF CONDITIONS <br /> �� � f� � The undersigned uwneriapplicant hereby agrees to hottl and save hartn ess <br /> �{ �,_ _��� /����� the City of Evemtt liom any anA ail claims for damages.costs.eapensec�or <br /> nppm.vr or Const� on p��� � causes ol actic,n Ihat may arise because o(installation and m�aiMenanc�:ol <br /> ihe improvement or other right-oFway use hereto applied lor and luriher ay�!es <br /> to mmove same upon notice from the City and to replace public prop•rty <br /> damaged Iherehy. <br /> FlNAL INSPECTION Date <br /> Approved as Conslmcted <br /> Signature ol i.pplicanl Dale <br /> Il'OFK AUTHORIZED[�Y Tl115 PFRMIT A1UST 3[START[D N9THIN 1F:0 DAYS OF DATE PERf.11T IS ISSUED ANO THEREA(7ER IS TO BE�IUGENTLY PURSUED TO <br /> Cn!dPl f i l�I: TI U:�=f i��.!^IT Lu.1� f-f.C�aN('(I LCU[3Y 11If.-CI I� UPi�ld,11JA�S�ppPAGE OF WORK ON THIS PROJECT OVER 90 DAYS DUHAT70N. <br />