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s <br />r <br />l� <br />L <br />r <br />Date�"y'�'3 <br />Applica�ion For <br />PUBL.IC WCIRKS PERaVIIi <br />Prinl or Type Only <br />f�b.�es ���. �aG S.E. C-�l: <br />.++ t <br />Applic2nt <br />ng Adtlress <br />', <br />Pu01ic Vlods Penmt • �"'!� � � <br />i <br />B�dO Dc; �. a _ <br />Public Wmks Poc S� V� G G <br />Totaliee <br />LeSs APpI. Fee Pald Cu � <br />BalanceCue $ a0',p� <br />. ,�3 3 � � _ <br />ssS-y`/y'Z <br />Phone <br />Phone <br />Describe Proposed Work Co.�or,^. A� w S I= /� _ <br />Pwject Address (if known) <br />Attach tour (4) copies of plans lor proposed work • Draw to scale and note the foilo��•in9 as applicable: <br />• Property Liaes • Centerline ol street <br />v Outline and dim�nsions of all existing and • Indicate North <br />proposed structures on the bt • Show any proposed grading changes <br />• Exisling and proU�sed utilities • Show measurements <br />PERMIT CGVDITIONS <br />t. All calls for inspection shall be made 24 hrs. in zdvance - phone 259•881 5. <br />2. All work shall be performed in accordance with this permit and current Ciry of Evere�.t Design and Consvuction <br />Standards antl Specii;aaticns. <br />.3/. Call Location Undergrou�d Service 48 hrs. belore you dic�. TOLL FREE NUMBER 1•800•424•5555. <br />Y, h��ust w..�r,� �et.��c� �.alve Uor ��.,.F,i �oi- �rwcie.,(� <br />.S. 1�ic<er - C3e 1+�� eu�e... e...i- Rn•� �'' ••_ i' �, l�e elecz.� r�.Y <br />�� ' � /3 � .P <br />pproved fo Construr,fion Dale <br />FINAL INSPECTION o ^ �� a� � <br />ApprovaA as Constructed <br />everett PUBLIC N'ORKS DEPARTMEI T <br />�� 3200 Cedar Street <br />Everett, WA 98201 <br />Phon¢ 259-A875 <br />� <br />AC.KNOWLEDGLMENT OF CONDITIONS <br />Z <br />C <br />H <br />� <br />� <br />a <br />The undersigned owner/apPlicant herzby agrees to hold and save harm- <br />less the City ot [vercit from any anA all claims for damages, costs, <br />expenses, or causes uf action that may arise because of installation <br />and maintenance ot the improvzment or other ri9h4of-way use hereto <br />applieA for and lurihe!r agrees to remove same upon nolice Irom Ihe <br />y and replace pyblic property damaged thereby. <br />� -Zi-Fr3 <br />Si aturc of Applic t uaie <br />ORK AUTHOHI � BY �iFtlS PEFMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERh11T IS ISSUED A�D THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON APIY STO?PAGE OF VJORK ON THIS <br />PHOJECT OVER 90 DAYS GURA-i IOn'. <br />1 <br />� <br />J <br />L <br />J <br />