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ti <br /> � q�/ -� � v'G�-�uu <br /> Date�{` fn Publ c Works P<<�i " /�/�—/� —/—}� <br /> / a/' J ' / <br /> BItlB JePt �_� <br /> Application For <br /> PUBL.IC WORKS PERiVIIT N�i�c`�'ornsFee _ <br /> tolal Fec 5 <br /> Les��AOP�.Fee Pa��tl $ 11 � <br /> Balance ouc ��v� <br /> Print or Type Only <br /> ��_ �. <br /> ,����-C�ti -�,�r-�G-r,.. /.1-.2 3 n `f � ,f'. �v t` � =�'in/z�z�,�.�C,t_ l�"; -0 9 SC- <br /> Ow�ier MailingAddress Ci�y ZiF .?�7� Phone <br /> �j <br /> (C� __.:, �r�_✓+'c �7i• ^��-c, � 7/"7 d G �.rresr.�f <F�a p�C� �'.(1i./ �� �1 C._S��'O <br /> Applicant <br /> 6 Mailing Address Ci�y Zip :tione <br /> Describe Proposed Work ��L������r* "� - �r������� _� <br /> �• � <br /> �� � �> f� _ /' � �i�..� • ■ <br /> Proiect Address(if known) � — <br /> LvT /G ,s <br /> Atlach four(4)copies ol plans lor proposed work- aw 1 cale and note the following as applicable: rn�, �je J �5 � <br /> • Property Lines • Centerline oi street <br /> • Outline and dimensions of all existing and s Indicate Norih <br /> proposed structures on the lot • Show any proposed grading changes <br /> • Existing and proposed ulili�ies • Show rneasuremen�s M <br /> W <br /> � DO NQT Wf71TE BELOW THIS LINE � <br /> PERMiT CONDITIOIJS <br /> 1. All calls for inspec�ion shall be made 24 hrs. in advance- phona 25g-SS��. � <br /> 2. All work shall be performed in accordance witn this permit and current Cily of Everett�e:i�n and Construction <br /> Standards and Specifications. <br /> 3. Call Location Underground Service 48 hre before you dig. TOLL fREE NUMBER 1-800•424•5555. � <br /> � <br /> �R <br /> _/ <br /> � <br /> � <br /> ACKIJOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees lo hold and save harm� <br /> — less ihe Cily of Everetl Irom any and all claims tor damages, costs, <br /> expenses, or causes of action ihat may arise because of installation <br /> � 7 + � and maintenance ol �he improvement or other right-ol-way use hereto <br /> Z.`r� ��`o�r��-- s �� �— applied for and furiher agrees �o remove same upon nolice Irom ihe <br /> �1pp�of ton,�slr�jction �a•e City and to replace public properry damaged thereby. <br /> �'�-'114�y.� �,�' / 7�z� f�— /' � ;' . � -yc <br /> F�NAL INSPECTION / \ " Date �r" . <br /> Approved as Constructed v ignature ol Appl' an Date <br /> WORK AUTHO IZED B1' THIS PERMIT MUSi BE STARTED WITi'IN <br /> everelt PUBLIC WC�RKS DEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Cedar Street BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT h1AV 9E <br /> Everett,WA 98201 CANCELLED 8Y THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone: 259-8815 PROJEC��OVER 90 DAYS DURATION. <br /> � <br />