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ChM>� <br />Axlx <br />q H <br />9HCA <br />� <br />�H� <br />� M � <br />�p H <br />�O� <br />OH <br />�^�g <br />y, V (� <br />zyy� <br />rHH <br />� <br />OC7ti <br />� � [s1 <br />�HV� <br />HOW <br />�'. <br />�� <br />�� <br />Date ���y�'% <br />,lpphc0lien Poi <br />PUBLIC WORKS PERMIT <br />Print or Type Onty <br />AOPhcani <br />' .;' I '� <br />TO PncriN�___���,�JL_ <br />Cny <br />I.tailinq AAd�ess Ciiy <br />�/, /i'/i <br />,,�.: „�..s,�..,�..�jp a�_��-� � <br />mnn oen� • —�+—( � - <br />Po4p[WonaFee __— — --. <br />.o�..�rP� '-----_ <br />n,�, nnni i.o va,u 5. _�� -`+---- <br />P.i� . Dur S • ) r . __ <br />Q�ecTr 3,53 " � <br />Zin Phonc <br />Pnon" <br />Descnbc Prot+osed �vork h P/� r' ���Li1i1�� -- -- — <br />Proiecl Add�ess Id knownl " '� � "'�"'"�Y�"�'—'—' <br />Attaeh low I�) copies o� Plans lor proposed wmk � D�aw ro scJe an� nole Ihe following as apPliwble. <br />! Properry Lmes <br />• Outline and d:mensions of a�i exisimq .ind <br />pwposetl slrucNres on Ihe lol <br />• E*�sOng and propaseA uiilrties <br />• Cenle�bne ol streel <br />• Ind�cate Norih <br />• Show any proposed gratlinc� r,hanges <br />• Shmv measur2mCn15 <br />PERMIT CON�ITIONS <br />1. All calls lor inspeclion shall be mad� 24 hrs. in advance � phone 259•8810. <br />2. All work shall be pedormed in accordance with this permit and current Cily of Everelt Desiqn and Conslmclion <br />Slandards and Specilicalions. <br />3. Cai� Localion Untlerground Service 4B hrs. 6efore you Cig. TOLL FREE NUMBER 1•800•424'S55 • <br />�/;� %;>, .� -.-, .�%j//., <br />Approved lor Consiruc jon Datc <br />v� / _ <br />��`���-�� ,�=-1 -iu <br />—= --._.. Date <br />FIrJAL INSP� <br />Ap�roved as <br />evdretl <br />� <br />ucled <br />PUBLIG WORKS DEPARTMENT <br />3200 Cedar Slrect <br />Everelt.'.VA 99201 <br />1="onc: 259�8810 <br />W <br />r <br />_ / <br />Z <br />O <br />� <br />N <br />O <br />a <br />ACKNOWLEDGEMENT OP CONDITIONS <br />The undersi9ced owneVapplic�N hereUy a9�eas lo holA and s^.. '�arm� <br />less ihe Ciry o� Everelt Irom any and all claims tor tlamap.:- ��sts. <br />expenses. or causes of , clion tha� may arise because ol ��,talL-'ion <br />and mamtenance ol thc improvemenl or othei righbobway vse herelo <br />�pplied �or anA �urther a9rces to re�nove same upon notic� trom ihe <br />Gty and o'iePl e pu Leprope� dama9ed ihereUy. <br />i /� <br />Gae <br />Si9naNre N APPhCani <br />WORK AUiH0�71ZE0'6Y THIS PERMIT MUST BE STARTED WITHIN <br />BE DI�L G[ML DPURSIEED TO'COMPLE�TION�TH S PER 11T M11 V BE <br />CANCELLED 6Y THE CITY UPON ANY STOPPAGE OF N'ORH ON THIS <br />PROJECi OVER 90 DAYS DURATION. <br />