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. , <br /> 1'u[�IiC lVnrk�P�.Irni�a _�[�/,���/. <br /> Date 5 6 2 � <br /> oia�� o�n� � --36628— <br /> �y Application For <br /> � � � WO R KS P E R M IT '"°"`"'°"5`°` - <br /> � P�IBLIC ,°"�"` $- <br /> p Lessnooi FenPnm 5 <br /> Cy N ('�( A,(� � � � � / -i%� <br /> ~ � ,�,� TO ��O J I I 11 V��1.�-•�"— e.,ia�ce o�0 5 _ <br /> '� Print or Type Only <br /> o "� o <br /> romN <br /> � � � PAIRMONT HOPIES INC 21902 38TH AVE W EVERETT C198036 356-Z4p 5 phone <br /> Owner Mailing AdAress <br /> � N <br /> M � Zi ?hone � <br /> � M Applicant Mailin9 Address City P <br /> H <br /> M y NEId SFR <br /> N �+ Describe Proposed Work <br /> C N <br /> � � � <br /> � N W <br /> ��� - l-t<<{ G� F'� >C LOT 7, BLACK FOREST LANE � <br /> prolect Address 1if known) <br /> � <br /> Attach four(4) copies of plans�or proPosed work� Draw lo scale and note the tollowing as apUlicable: � <br /> • Property Lines • CeNerlir�e ol slreet <br /> � Indicate North <br /> • Outline and dimensions ol all existing and � Show any proposed grading changes � <br /> proposed structures on the lot • Show measurements � <br /> • Existing and pwposed utilities I <br /> DO N07 WRITE BELOW THIS i.INE O <br /> PERMITCONDITIONS ^ I <br /> 1.All calls for inspection shall be made 24 hrs.in advance-phone 259•(3£f1•7 <br /> �///��� � �\ 2.All wo�k shall be pedormed in accordance with Ihis permit and curreN City o.t Eveiett Design and Construction ♦ <br /> j �'' StandardsandSpecifications. � <br /> ` 3.Call Location Underground SPrvice 48 hrs.before you dig.TOLL FREE NUMBER 1•800-424•5555. � <br /> l �� }..)u ev�crou�",'-e,���{- cc 1(��ed ,l�-l� i� ' � l-� � i �-�� ��e�^��— O <br /> ��� <br /> , �� {' ven��lcw�c� �. �p <br /> j ivt c�v��^t' �o 0 <br /> I �_ r/ <br /> O <br /> ; _� <br /> a <br /> .� ' _ ACKNOWLEDGEMENT OF CONDITIONS <br /> ,�,�� � ��� The undersiqned ov:neVapplicant hereby ag�ees to hold and save harm- <br /> � less the Ciry of Everett Irom any and all claims lor damages, costs, <br /> i A expe ses, or ca�:�es of action Ihat may arise because ol installalion <br /> �`�/�//�,'�/� r��� �c9i1 antl iintenan�e o! 'c� imprcvement or olher right-obway use hereto <br /> � /('/ 7.0 � / C� apP ie tor antl fi�:ihc�r a9rees to remove same upon notice from the <br /> �� � Approv d br Construction /� Dale Cit a to replace puolic p�oPerty dama9ed lhereby. <br /> % � <br /> , _i lt�=! _' _/L �L-_" `7 1/ <br /> ' FINAIINSPECTION Datc Dale . <br /> c i qpplicanl <br /> Approved as Constructed p ORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> ��r� PUBLICWOFtKS�EPARTMENT 180 D S F DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAl' BE <br /> E�,;�e�t,Wq g8201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WOriK ON THIS <br /> Phone:259�8810 PROJECT OVER 90 DAYS DURATION. <br /> I <br /> 1 <br /> M <br />