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x <br /> i L� <br /> Date�=4-9D a„oi��wo,ksrP,m��. 90 3� <br /> B ep o.o� • .�D�25$14 <br /> �� Applicalion Fbr <br /> ti __-- <br /> PUB�.IC WORKS PFRMIT °°°'°w°.`=`Ce <br /> Tolal Fec S <br /> O Les3Rppl Fee�ai� 5 - <br /> O <br /> Print or Type Only s <br /> S � � `� � � � g8a A.,.,,,..o,.. S 20— <br /> O� O o O `G O O d P O� <br /> � p. '+ �1 N M CJ M h �d' ao <br /> �O .y .ti N N M N M CM+/ <br /> N M N N J � <br /> � <br /> T D Dubuque o 528 ice Rd Sno mish 980 339-2853 <br /> Owner � NMailing A � s�- �7C �+ I `• Cdy Zip Phone <br /> ,.My 0J �JU�J � � � �w0Z � W <br /> � �O] 6. L � d � YNA� ti [=_` <br /> Owner � — <br /> Applicanl M1ladinq AAdress Q�y Zip PhOne <br /> Describe Pioposed Woik _Slew__dupl� �— <br /> -,�tr� �.d,- a W <br /> P�olect Address pf known) 55��_��d11ilY5t_ -- � <br /> Attach four 141 copies ol plans lor proposed woik- Dr�w lo scale and note ihe lollowing as appliwhie. � <br /> • Property Lmes • Centerhne of street � <br /> • Outline and dimensions ot ail cn�sting and • Indicate Norin <br /> proposed sVuclures o���he lo� • Show any propOsed gratl�ng ch:inycs <br /> • [ais�inq anA proposeA utditie�s • Show ineasurrmenis � <br /> DO NOT WRITE BELOW THIS lIN[ O <br /> PERMIT CONDITIONS <br /> 1.All calls for inspeclion shall be made 24 hrs.in advance-phone�2b9•S8�0. ' ^ <br /> 2.All work shall be pedormed in accordance with ihis permit and curren!Ci�y ol Everett Design and Consiruction d <br /> Standards and Specilications. <br /> 3.Call Location Undergromid Service 48 hrs.belore you dig.TOLL FREE NUMBER 1•800•424•$SFi$. � <br /> O <br /> � <br /> � <br /> O <br /> a <br /> � � <br /> ACKNOWLEDGEMENT OF CONDITIOIJS <br /> � I1' The undCrsigneU owne�iapU6caM hereby agrees to ho�tl Jntl save harm- <br /> --- -- less the Cdy oi Everett irom any and all claims for tlamages. cosls. <br /> eapenses, or causes of action Ihat may a�ise because ol installation <br /> 1�� „�/� C KQ� �—1�—yO and maintenanr,e of the impio+ement or olher right�of-way use hereto <br /> �Y � applied �or and furihei agrees to remove same upon notice from the <br /> Apniovetl lor Construction � Dale �i�y and b rep ar.e p �Nc pwperty Aamagcd IhereUy. <br /> �/ J� � <br /> //"�l�- 3- � � s'i %� y ��� //�3•-9� <br /> RN�L INSPECTION Date <br /> Appioved as Construcled ature of App6cant / Date <br /> `WORK AUTHUR2ED B THIS PERMIT MUST RE STARTED WITHIN <br /> �.��•i�.�; PUBLICWORKSDEPARfMENT �gp D�YS OF DATE PERM1117 IS ISSUED AND THEREAFTER IS TO <br /> � 3200CetlarStreet BE DILIGE�TLY PURSU[D TO COMPLETION. THIS PERMIT MAV BE <br /> Eveiett W�19B2J7 CANCELLED BY THE CITY UPON ANY STOPPAGE OF bVORK ON THIS <br /> Phone�.259�8810 PROJECT OVER 90 DAYS DURATION. <br />