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�2�R_If–�lid'}j emucwo,��r., GL�Vp__p /c�� <br />Applicatian Por fl'nu oeo� � ��r ��_u-7 _—. <br />PI�BLIC WORKS P�(����� �, I� �,� � ---- <br />P„-<wo,..�., s <br />.��.� �.. <br />i'rint or Type Only <br />«,,.�o� �,� o. o s — <br />ea�,�<.o�0 5 aU�— <br />I�if��(..�.0 15'1L�Y NG /�(D�".Si lA/r,r,r�;,.i..'// U�//� Q8U7a _ <br />Owner MailingAndress Cily Lp PLone <br />��` .�'�J�{� �183-Sa�r�- <br />Ap' pli�y�( ' MailinyAtltlmss Cily Zip P�one <br />Dnscn�e Pro��oscd Work _� p G 1 �1-twi�4r---1L(lYJ[� <br />!' <br />Project >dtlresslil known) <br />' _ . . - �pit Kd <br />Altac�. lour �4� copies ol plane br Oroposed work � D�aw lo sr�le and nole the lotlewing as appliwble: <br />• Pmpetly Lines • Centerline ol stree� <br />• OuOlne and dimensions ol ali eaisting artl • Indicate Norih <br />pmpo5e� 5imc�ure5 on Ihe lot • Shaw any pmposetf gratlinp [nanpes <br />• Evisting antl pwposeC u�illlies • Sliow measwements <br />PERMI ( CONOITiONS <br />1. PII calls lor Inspec�ion shall be ma0e 24 hrs in advance- p�one 259•8810. <br />2. All work shall Ea pedame0 in accordante wi�li ��is permi� antl cvnent City ol Ererell Design ane Construction <br />SlandarEs antl Specilica�ions. <br />3 Call Localion Untlergrountl Servicn 48 hrs. betore you diq. TOLI FREE NUMBEH 1•8U0•424•5555. <br />—���s`�l��� y�si9B <br />ApPmveye� Cor 'uct :n Dale <br />� r n / <br />ar� G/%�� �� �i�o �'�_ <br />.�� <br />FINAL I SPECTION / Dale <br />Approvetl a5 ConStruCteG <br />evereu �UBLICWORKS�EPARTMENT <br />� 3200 CeCar Streel <br />Everelt. WR 09201 <br />Phone:259�88�0 <br />AC :NOWLEDGEMENT OF CONDITI045 <br />W <br />H <br />� <br />ZI <br />O <br />H <br />c� <br />O <br />a <br />T�e untlersignea owncr/nppLcan� hereby a9ree; to �old and save harm� <br />less Ihe City ol Evcietl Irom any and ali uaims for tlamane5. cosis, <br />e.penses. o� causes : I action t�al m�y anse because ol mslallabon <br />antl maiMenance ol I[e Impmvemenl o� athcr nghPo4way use herelo <br />aOPlied lor and Iu�iner a9rees Io remove same uoo� nol�ce Irom t�e <br />Gty antl m replace pubhc properry tlamagetl ��ere0y <br />1 Y�V � 'v�y� b — nl ^ '� `\ <br />Signature ol AOCIicaCll � Date <br />N'ORK AUTHORIZEOI.i� TMIS PERMIT N.UST BE STARfED WITMIN <br />190 DAVS OF DATE PERMIT IS ISSUED FN� iHEflEAFTER IS TO <br />9E DILIGENTLY PURSUED TO COMP;.ETION. THIS PERMIT IdAV 9E <br />CANCELLED 6V THL CITV UPON ANY STOPPAGE OF WORK ON THIS <br />f ROJECT OVER 90 Ot�YS DURATION. <br />