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Date c `� r <br />qpplication For <br />PU�3L�C �JORKS PERIMIi <br />Print or Type Only <br />�� �r R v��r� �� <br />T— Osvner <br />�_3 �.� = `%r �_�i,'— <br />Address <br />C � <br />Describe Proposed Work _ � - <br />city <br />, <br />y`7'.f/ i���.'4 � <br />PUW�c Waiks Pormit A � ' �y� <br />umn o�o�.. �r y// 3 � <br />rublic`.vo�MSFea 5---� <br />Total Fuo <br />Less APr � Paltl S —/�— <br />Balance Duo S ��1 �=` �— <br />,��- <br />a s� - 3 �,3 :� <br />Z�P Phone <br />�;,, phone <br />��_ _^ � � — <br />a 3 /.i � <br />project Address (if known) <br />Attach four (4) copies ot pians for proPosed work - Drew to scale and note o`1o11efline of street a��le: <br />• Property Lines • Indicate North <br />• Outline and dimensions of all existing and s. Show any Proposed 9radiny chany=s <br />proposed slructures on the bl e Show measurements <br />• Existing and proposed utilkies <br />_ � 1c a i_OW THIS LINE <br />PERMIT CONDITIO�JS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259'881 <br />2. hll work shall be perturmed in acrordance with ihls permil and currenl City of Everett Design and Con`,vuction <br />Standards and Specifications. <br />3. Call Loca�ion Underground Service 48 hrs. belore You dic�. TOLL FREE NUMBER 1'800•424•555 . <br />i <br />J'� ! // i�� <br />`";- ..�,� ��_�f�''�' / oa�e� <br />Appro+cd tnr Copslruc�ion ` <br />�/� � W <br />" d-_____��t=�e—"1� ` J Date <br />RNALINSPECTION � \ <br />Approved as ConslruclPdv � <br />evcrelt PUBLIC WORKS DErARTMEN� <br />� 3200 Cedar Street <br />Everetl,'NA 98201 <br />Phone:259-ft815 <br />�' <br />t <br />ACIWO\'JL[DGEMEi�1T CF CONDITIONS <br />The unders�gned owneUapplicant hereby a9rees to hold and sav'e harm- <br />eexpeoses,'or ca sesr otf acl onathat mayiar se becau e,oiag stallatlon <br />appl ed'tor and fu�the Qac�reesVto remove 1 ame opon noGce trom the <br />City and to replace public proPerty damaged thereby. <br />C-! / " - � " �' �� � Date <br />Si atur of APPlicant <br />WgORDA STO�F DAT�E PERMIT S SSUED ANDBTHERFAFT�ER ISHTO <br />BE DILII"aENTLY PURSUED 70 COMPLETION. THIS PERMIT MA'f BE <br />pqpJECT OVBGR 90 DAYS DURAT Jp� STOPPAGE OF W���<CN THIS <br />z <br />0 <br />y <br />n <br />rn <br />.-, .-� <br />�..� T; <br />1-v �{ <br />� Z <br />0 <br />m <br />cc <br />m c: <br />r: <br />.-� c <br />� �� <br />-i � <br />2 --i <br />/� Z- <br />c <br />y •-' <br />rx <br />.. �. <br />� � <br />-� <br />O N <br />TI S• <br />� m <br />T <br />m �� <br />N <br />or <br />�m <br />c v� <br />m `" <br />z n <br />--{ r <br />. m <br />a <br />� <br />� <br />� <br />�. <br />c` <br />-1 <br />c�-� <br />m <br />