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� <br />K1C11� <br />yH <br />�Hxf�i� <br />H x� <br />K A <br />H 7J <br />� H'� <br />V1 H <br />ti7 O � <br />OH <br />H�8 <br />�Y � <br />zy��HH <br />N <br />C� C7 y <br />� � t� <br />x H Cn <br />H O �n <br />Date 6/1/92 <br />Application For <br />PUBLIC WORKS PERMIT <br />PrintorTypeOnly T� PQJT�N�__ /G-_L`(=Q_t <br />I c�oxc wnrps Pc�ma .�� ' �/ � <br />eiag oem • 36882 _ <br />Pu�hc lVorks Fee 5 <br />Total Fee - <br />LC59 (�pPl FBP P�rl1 �J � <br />aa����„ o�� s 1_ c_ <br />.,r� - � zzv��i�„''� � <br />William A Jacka 3230 54th St SW FJ��*' 9R?0� 95'i Rna� <br />Owner Mailing Addre�s Cily Zip Phone <br />Owner <br />qpplicant Id'eding Atltlress <br />Family rocm addition, new <br />Describe Proposed Work <br />Project Address Uf knownl <br />9270 54rh Sr Sta <br />re-roof <br />Zip <br />Attach lour (4) copies of plans for proposetl v:orh � Drav+ lo scale and nole the lollowing as apPlica6le: <br />.___ . • property Lines <br />• OuUine and dimensions ol all ezis�ing and <br />' propOsed struCtures on Ihe IOI <br />� • Existing and proposed utilities <br />.; <br />• Cenlerline ol street <br />• Indicate North <br />• Show any proposed gradinr� changes <br />• $hOW rt1P.d5U�CnIE�IS <br />�hone <br />PERMIT CONDITIONS <br />1. All calls lor inspection shall be made 24 hrs in advance � phene 259•8810. <br />2. All work shall be pedormed in accordanr,e wrth this permd antl current City of Everett Design and Consiruction <br />,itandards and Specifications. <br />3. Call Location Under9round Service 4B h�s befcre you dig. TOLL FREE NUMBER 1•� �0•424•5555. <br />i� <br /><�` <br />� /�-/:�.i�`G-�'� G' y// <br />�pproveC fo� Constructi i ���e <br />�� /O -`�� 3' f�i <br />FINAL INS CT D�te <br />Approvetl as Construc�ed <br />PUBLIC WORKS DEPARTMENT <br />3200 Cetlar Street <br />Everelt. WA 98201 <br />Phone:259�8810 <br />';:5�.:' <br />t <br />ACKNOWLEDGEMENI OF CONDITIONS <br />W <br />� <br />�� <br />Y/ <br />�� <br />� <br />Y/ <br />O <br />a <br />l liv undr.rsigned owneVnpplicant hereby ay�ees In hold and save harm- <br />L•ss the Ciry ol Everetl iwm any anA �II claims lor damages, costs. <br />expenses, or causes of action that may arise because of installation <br />an<f maintenance ol Ihe improvement or other n9hbof�way use here�o <br />applicd br and fur�her agrees to remove same upon notice Irom the <br />Cdy anA to re�loce Uu61ic property dama9ed �I�ereby. <br />it/ c.c'l� � _ '��,— (° -/ 9 � y�— <br />Signa�ure ol Applicant Da�e <br />WORK AUTIIGFIZED BY THIS PERMiT MUST BE STARTED WITHIN <br />1F30 DAYS OF DATE PERMIT IS ISSUED AND THERE�FTER IS TO <br />B[ DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY B[ <br />CANCELLEU BY THE CITY UPON ANY SiOPPAGE OF WORK ON THIS <br />PROJFCT OV[R 90 DAYS DURATION. <br />