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Date��� r��oi�c wa�ks PGe�/m,(n• �`'�/�{�' �� — <br /> Blpp.Oepl� QL//3T/V <br /> Application For � <br /> PUBLlC '1MORt4� PE�t1�IT PubT�leFeeFoa s �.�J.00 <br /> Less ipo�.Fao PaiE $ — <br /> Baianca0ua g ��U' �U <br /> Print or Type Only � �f%3 <br /> Ron S��M%� Spelhaug 3116 113 Place S.W. Everett 98204 <br /> �{XXQtXXXRl{%XIKXR�tXK�XX '-� JI.�� // UC��f'7"I�11 �pPl2'H /��fI. 7���i� ��J'7 - e�:J <br /> OH�ner MaiGng Address City Zip Phone <br /> Sane r <br /> '�x�xxx�xx;����ac��- ���iG--Il.�{!; !�lS'l�� /"Ili-'iC�/ �(�� �i�:�D�/ :353 -035� <br /> .4pplicant Mailing Address City Zip Phone Z <br /> 0 <br /> -1 <br /> � ),� �� � , �, <br /> Describe Pr�Posed Wark �'�3� ��-�� — r;' <br /> -- .. � <br /> —� '*l <br /> 5.G.. r.-� —i <br /> /a a 9 it� '` .�,�. � .— _ (� N = <br /> m <br /> Pro�ect Address(if known) � �� �I�� ���P��J — � c o <br /> mo <br /> � <br /> PJtach four(4) copiEs of plans for proposed work- Draw lo scale and nola the following as applicable: d � � <br /> � � m <br /> a Prooerty Lines • Centerline of streel � Z <br /> O Outline and dimensions of all existing and • Indicate North z -'{ <br /> • Show any proposed gradiny d�anyes m <br /> proposed struclures on the lot � Z <br /> i Existing and proposed utilities 0 Show measuremenls � � <br /> y -a <br /> � DO NOT WRITE BELOW THIS LINE � �-' <br /> � —i (n <br /> PcRM1T CONDITIONS � '� <br /> o � <br /> 1. All calls fur insp�ction enall be made 24 hrs. in advance- phone 259-8815. � � � <br /> ::. All work shall be performed in arcordance with this permit and current City ot Everett Desic�n and Construction .i � <br /> Standards and Specifications, r,�; .. <br /> 3. ^all Location Underground Service 4C hrs. belore you dig. TOLL FREc NUMeeR 1•800-424-5555. � v� <br /> o � <br /> � C N <br /> f3''i N <br /> zn <br /> -i r <br /> m <br /> � a <br /> � <br /> V� � <br /> S <br /> � � <br /> � <br /> � C <br /> -� <br /> C <br /> fO <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undarsigoed owner/applicanl hereby agrees to hold and save harm- <br /> — / less Ihe City ol Everett from an� �nd all claims for damages, costs. <br /> `� _ /� '/ exPenSes. or causes ol action lhat may arise because of insfallation <br /> /���� J��'-c�,i'oT and maintenance of lhr; improvement or o�her righPol-way use hareto <br /> «� � applied tor and further agrees lo rcmove same upon notice irom �'�e <br /> Approved�or Consiruclion + Dale City and to re public property damaged lhereby. <br /> � �� -/ � /' �,-C� - ����/�S <br /> FINAL IN CTION Date / � � <br /> Approved as Constructed � Si at re of A ir.ant � Date <br /> WORK AUThiORIZED BY TNI ERMIT MUST BE STARTED WITHIN <br /> everett PUBLIC WORKS DEPAR7i.".ENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 5200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY 8[ <br /> Everelt,WA 38201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Fhone: 259�8815 pRUJFCT OVER 50 D1VS DURATION. <br />