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1 <br /> Date�� �/�� �' Vub4c Ww�a Perm�t• <br /> •-�� �' '"� <br /> 6iaq Oeot • r5 <br /> �pplicalion For <br /> PUBLIC 1�IORKS PERMIT vuNicworkaFen .—� <br /> Tolal Fee s <br /> O <br /> lessRpV� FeePa�a - <br /> O <br /> x g g g �O � g g $ g g Baian<e Dur S <br /> Pnnt or Type Only � g o o, r,; � a � o ,.. <br /> � a r7u�i m � �w w w t�— o <br /> ti w P M M N �..(_ C� <br /> j V I I � �.� �� 1'11v' ��'��J ��1�� ��- � _l � �p'l�r �i I'.�� � P,T�-1�`� <br /> Owner ty o�'F+ � � �i c�i � a N ��rYw Z'p <br /> 1(�t � c-I� ���� e -� ' `�-,�a�,��'}- %�"---�'-�-�d I 91 <br /> 1'�` APp�� Mailing Address City Zip Phone <br /> Describe Proposcd Work � ^�/�1—+S '���—'/� <br /> W <br /> Prolecl Address lil known) � �� � ' � <br /> Attach lour�4) copies of plans lo� P�oposed work- Draw to scale and note ihe fo�lowing as appGcable�. � <br /> • P�operry Unes • Centerline of street � <br /> • Outllne and dimensions ol all existing and • Indicate North <br /> proposed S�ructwes on the lot • Show any n�oPosnd gradmq changes <br /> • Enisbng a��d P�oposed utilitics • Shov: measurements M <br /> W <br /> DO NOT WRITE BELQW THIS LIN[ O <br /> PERMIT CONDITIONS <br /> 1.All calls tor inspeclion shall be made 24 hrs.in advance� phone 2$9-88�0. � <br /> 2.All work shall be peAormed in accordance with this permit and current City ol Everett Desic�n and Consiruction <br /> Slandards and Specifications. <br /> 3.Call Location Underground Service 4B hrs.belore you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> �, . 2/�' 1,.�_.',� CJ?-- O <br /> , .:� <br /> �, ��i� /'��-f' fi�c 7 � cn� �� <br /> s-.�'cJ.�'t)%�•c�,C_` %��.�'—�7 .1/'—=�� ;��'�J' .�/� " .--.�'L--'�.� � <br /> ��S �i� � . ��� � iL��".. ,!'�1 .. ��-, � <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owneriapplicant heieby agrees to hold and save harm- <br /> - less the Cuy c! Everett irom any and all claims for Aamages. costs. <br /> � / � expenses, or causes o� action ihat may anse Uecause ol installation <br /> i <br /> �r'— and maiNenance of Ihe improvement or other right-obway use ere o <br /> ��/�� � �� �'r2'/ � appli� for and �urih�c r agrees remove same upon notice Irom ihe <br /> Anlrioved for-CoPelPuction / � Date ity. nd replace�lic properry ed �here6y <br /> ^-��/� ���`/ ,��n- Fi c�_ l 2 2 <br /> F#NAL INSPECiION �1e Date <br /> Approved as Consiructed Signature ol Applicant <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> rvr�iq� PU3LIC WORK3 DEPARTMENT 180 D�YS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CedarStreet BE DILIGENTLY PURSUED TO COMPLETION. iHIS PERMIT MAY BE <br /> Everell.WA 96201 CANCELLED BY THE GITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phona 259-8910 pROJEGT OVER 90 DAYS DURATION. <br />