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�v /��- <br /> (� vuobc wo�ka Permn• / <br /> Date % �iae 000i ���G <br /> Applicalion For — <br /> tiVORKS PER9Vi �T Puoncwa�teFoe $ �p rjp <br /> �U���� Tolal Faa <br /> �� <br /> Lesa AoO�Feo PaiE .g <br /> Baiance Dua $ ��' � � <br /> Print or Type Only �SU <br /> .�J`.�'.� <br /> (� ��,R J �a �- fvF' �r'�� l)1/�/� //_)t)-y y �S�c � <br /> f�JS)���RA'� J iJ i�[ � � / S � L Ci�Y Zip Phone '— <br /> Owner ^ Mailing Address <br /> . �'j�yy� � - <br /> —� Ciry Zip Phone <br /> Applican� Mailing Address <br /> � (� � ' <br /> �u � 1 c� i u� s. v��4 �� F�n� �C � s, � �v �. �f -- <br /> Describe Proposed Work —��---� <br /> �... <br /> � <br /> n5��3;�G� '�- P�� S� t='v �Re, T' �° <br /> Prolect Address(if knawn� / # �� <br /> Attach(our(A)copies ot plans f�P�Po:�'�work� Draw�o scale and note lhe following as appliwble: � <br /> • Properly Lines ! Centerline of sireet <br /> • Indicate North <br /> • Gutline and dimensions ot&.II existing and � 5�,.�W any proposed g:2din�chan9es <br /> proposed structures on th� lol • St�ow measuremenls � <br /> • Exis�ing and proposed utilili=s <br /> ���� DO �JOT WHITE BELOW THIS LINE � <br /> PERMIT CONDITIONS � I, <br /> 1. Ali calls tor inspection shall be made 24 hrs. in advance- phone 259•881 b. i <br /> 2. All work sh211 be performed in accordance with this pamit and current City of Everett �esign ana Construr,tion <br /> �landards and Specificalions. q� � <br /> 3. Call Lowlion Underground Service nU h-s. belore �ou dig.TOLL FREE NUMBER 1•800•424-55b S. � <br /> r <br /> � � <br /> � <br /> � H �- <br /> -� " <br /> � � � <br /> rr. F <br /> c <br /> � � r <br /> ca _ <br /> � ` <br /> . - � <br /> a � <br /> � <br /> ACKNOW�EDGEMENT OF CUNDITIONS c ' <br /> 7he undersigned owneq..ppliczN hereby agrees�o hold and save harm- H �� <br /> --- � less the City ot Everetl from any and all claims lor damages, costs, � <br /> ' ezpenses, or causes ol action ihat may arise because ol ins�aila�ion �-:�; r� <br /> � ���=G �_ �� and maintenance ol Ihe improvement or other right�of-way use here�o � <br /> applied fcr and lurther a�rees to remove same upon nolice irom Ihe <br /> ,Ap¢tove�d r Constr���ion Date City and to replace public property damaged Ihereby. _,. �' <br /> � I � ; <br /> -_-__� ���':�l � �� ' (G r� � A <br /> ,/�- �,�� � � G ��i ���`� r : <br /> FINAL I CT ��� ���—aate <br /> Signature f licant � " <br /> Approved as Consirucled 7 <br /> WORK AUTHORIZED BV THIS PERMIT MUiT BE STAR'fED WITNIN <br /> everett PUBLIC WORKS DEPAf7T E�T 1B0 DAYS OF DATE PERhtIT IS ISSUED At1D THEFEAFTEA IS 7U <br /> � � 3200 Cedar Sireet 9G DILIGFN iLY PURSUED TO COMPLETION. THIS FERMIT AAAY BE <br /> Everetl,WA 98201 C4NCELLED BY 1'Ir GITY UPON PNY SrOppFGE OF WC3K n� THIS <br /> Phone: 259�8815 PROJECi O"�H f!G DA1'S DURP.TIOtJ. <br /> l . <br />