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Date <br />Applicalion For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />PoUbc Wor�.s PermA � � <br />B�Jp Den1. ♦ <br />PopL< Wodt Fne <br />To�el Ppe S <br />Lese 40GI. Fee Pe�E S <br />aa�a��eo�, s �S �g4' <br />Ronald H and Thelme Hsnsen ',827 Rucker Av EWerett Waeh 9820� 2s2 212'I <br />Owner Mailing Address Cdy Zip Phore <br />Same <br />Applicant <br />Describe Proposed Work uee Att: <br />Prolect Address (if known) <br />Same <br />Address <br />Same <br />3725 �cker Av �rerett, Waeh. 98�1 <br />Z�P Phone <br />Attach four (4) copies ot plans lor p�oposed work - D�aw to scale and note the lollowiny as applicable: <br />• PrOperty Lines <br />• Outline antl dimensions ol all existing and <br />propo5ed Structures On the lo� <br />• Existing and propo5ed utilities <br />PERMIT CONDITIONS <br />• Cemeriine ol sireet <br />• Indicate North <br />• Show any proposed grading changes <br />• Show measuremenis <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All work shall be performed in accordance with Ihis permit and current City of Everetf Design antl Constructlon <br />Slandards and Specilications. <br />3. Call �ocation Underground Service 48 hrs. belore you dig. TOLL FREE NUMBER 1•800•424•5555. <br />y /L�O.�,t To ,BF ,l.Y�ti��" i-'f~,�' ,diJ',� n�.�D /-'ce.ti`-s <br />,L�.a TFO //2 fs'S <br />���L� � <br />�l <br />G <br />lor <br />� <br />', � 5�11� I G ��-��� <br />� � Iti <br />5 <br />� ��� <br />Wo� <br />everrtl PUBLIC WORKS DEPARTMC-NT <br />� 3200 Cedar Street <br />Everetl, WA 98201 <br />Phone�. 259�8815 <br />Date <br />Date <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />O <br />The undersi9neA owner/applicant he�eby agrees to liold and save harm� <br />less thr. Cily ol Everelt irom any and all claims lor damages, cost�, <br />expenses. or r,auses of action thal may anse because of installation <br />and maintenance ol lhe improvement or other nght�of�way use hereto <br />applied lor and lurther agrees to remove same upon notice Irom ihe <br />City and to replace nublic preperty damaged Ihereby. <br />?F���/l;r�t�s/�--��� , ,� <br />, <br />� � Ot ^ � ,,.;� <br />nature oi Applicant Date <br />WORK AUTHORIZED BV THIS PEHMIT M T BE STARTED WITIiIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />B[ DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT IdAY BE <br />CANCELLE� BV fHE CITY UPON ANY STOPf'AGE OF WORK ON iHIS <br />FRO.iECT OVCF 90 DAYS DUFATION. <br />z <br />0 <br />�--1 <br />n <br />m <br />.+ ... <br />.--� T <br />�--i �--1 <br />N 2 <br />m <br />�o <br />mo <br />-� c <br />om <br />--i z <br />2 --1 <br />m <br />o z <br />r x <br />.-i �. <br />--1 �/% <br />< <br />T <br />O .T� <br />T 3 <br />im <br />m� <br />O N <br />n rr*� <br />c cn <br />m� <br />�� <br />. m <br />a <br />� <br />-� <br />x <br />a <br />� <br />� <br />r <br />