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" '-'' <br /> r <br /> '1 <br /> � <br /> -I/ Pue4cworh.pe,mit.� " '�• l] <br /> Dale ����2 <br /> Application For omo.oeo�-• <br /> PUBLIC WORKS PERMIT �ubl¢Work�Fea ,_� .�._� <br /> Tob1 Fee S ` <br /> �� v.. <br /> Lesa AoOL Fee PUE S �� <br /> r _ �,-- <br /> Beiance Due S !� <br /> Print or Type Oniy <br /> { <br /> �ii7 �. ,f�,� , ,�� : , �J��.� <br /> -"i7!-',�f= �JA((�h.�%�i9 .�iGr�C'Y'�' !'/�G ���,/•, �� �c:1y� -;>d- -;G`Dc <br /> Owner ldailing Address C'ry� Zip Phone <br /> ��i �^^ '�' — <br /> Applicant ldailing Address City Zip Phone <br /> T -%.// ��i�.7 i'L� qt� !`/!i",�/� [?�ln s i�t'��7/;� <br /> Describe Proposed Work .� �., / <br /> 'iic'�F 'S� � �/�l�/li=/? �ty' <br /> W <br /> Lv�T .�i�tir�c� �cr-!T - s.is "�;�:�v,;�.� l-voy � <br /> Project Address lif knewn) � � <br /> Atlach four(A)copies ol olans for proposed wo�k� Draw to scale and note the tollowing as applicable: � <br /> • Property Lines • Centeiline of sireet � <br /> A Outline and dimensions ol all eaisting and • Indicate North <br /> proposed structures on Ihe lot • Show any proposed g�ading changes <br /> • Ezisting and p�oposed utilities • Show measuremenis M <br /> W <br /> - DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1. All calls lor inspection shall be made 24 hrs. in advance�phone 259•8815. � <br /> 2. All work shall be perbrmed in accordance with Ihis permit and current City of Everett Design antl Consimctlon <br /> Standards and Speciiicalions. <br /> 3. Call Location Untlerground Service 48 hrs.belore you dig.TOLL FREE NUMBER 1•800•d24•5555. � <br /> �` y�i'- lrci.��.� ` U- (f�lt�Rr .CI `� \..._i��� l � Clr�v�� �,.. n�1 ' O <br /> �?�IST\J\ ��ra,......,�_ p.+ l-���� .� s u�r. ...u�1-�v�a� ckl �c���/� <br /> 5. IVO qlft�C�vl� �or , r.... .y �� \t.� .-_'4 �a.� �l n<�i ....,c-\r'.?/ „v .`4�%. � <br /> 1 � \ /w <br /> �.t (�e�._., ��-_. VC <br /> O <br />� <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owneqapplicant hereby agrees to hold and seve harm- <br /> less ihe City of Everetl Irom any and all claims for dameBes, costs, <br /> / expenses. or causes ol action that may arise because of Installetion <br /> – -� y�a/V and maintenence of the improvement or other rigM-obway use hereto <br /> � � ����.`� �--- applied IOY u lurthe�)aprees to�remove same upon notice irom the <br /> ppr�d br Constructio Date City and to r pl�ce'pudlic property damaged thereby. <br /> � � � <br /> L - � 81f�� � �� ' �� � � ��_ <br /> - , �-iz- � � 'J <br /> � INSPEGTION Date � % �� � '��� "�- <br /> Approved as Cunstructetl SignAture ol PP itaFt– Da�e <br /> Oeverett FUBLIC WORKS DEPARTMENT �'�'ORK AUTHORIZED BV THIS PERMIT MUST BE STARTED WITHIN <br /> 180 D�VS OF DFTE PEF7MIT IS ISSUED AND THEFEAFTER IS TO <br /> 32D0 Cetlar Street BE DIIIG[NTLY PURSUED TO COMPLETION.THIS PERMIT MAY BE <br /> Everett.LVA 38201 CANCELLED�Y THE CITV UPON ANY STOPP:GE OF WORK ON THIS <br /> Phunc:259�L815 PROJECT OVER 90 DAYS DURATION. � <br /> �- J <br />