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�ate� <br />Application For <br />PtUBLIC WORKS PERMIT <br />Print or Type Only <br />��d �1 �1�.L��1.1L �� ��aS �� �I�� -��/ <br />n(.;ro: ��'— Mai4mg Addr25s City <br />PuOLc 4Va�xa Permq • — // / <br />eiaa.oea�.+ _�� <br />PuOuc Worxs Fee 5 <br />Talal Fee <br />less AOot F« PaiE S <br />Baqnce Due $ �O � <br />Phone <br />� Applicant Mailing Address City ZiP Phone <br />� <br />Describe Proposed Work <br />Prolect Address (if known) <br />Atlach four (4) copies ot plans for proposed wor <br />• Property Lines <br />• Outline and dimensions ol all exist <br />proposetl structures on the lot <br />• Existing and proposed utilities <br />PERMIT CONDITIONS <br />1. All calls for Inspection shall be mac <br />2. All v+ork shalf be performed in accc <br />Standards and Specifications. <br />3. Cali Location Underground Servic� <br />� <br />C/ b w`�`i, a � J'�+'- <br />p wT cc K Y <br />Cf r G`� �L� V r� <br />i �. ) /"7 � c�. . ., S <br />W � �1..._ <br />�! D"�- fJ I U T` I � l. 0 1 O J` <br />� o c ti <br />C�G`or�t3 u..��,.e�_•n <br />i��� /��.z�.�-,� �.�.� �..��.' �. �.k��.. <br />�. <br />� a „ ��,G� �'a.a��D�if.-�� o--z.�-r2 `i'' � <br />C�n.,u�/Z�Q ��n,r�� ��o Co��i , <br />,$" �,.�,��z`� C��z,�'� ����r� �a �i���(-ci <o ��'�-�� <br />O � <br />� <br />for <br />� <br />� <br />♦�P <br />Vg <br />� <br />� <br />/`j"�"�/� 2�o7��-c��o�,-� � cict���-�`or�z/f,l�-u� <br />On� .�' o .CN//`' GU/J(�����/��Jljy�X��J 2r� .iCmvZ�zcc��aiJ /G'cU:fJ� <br />���� �i�^of� �r=��.EG✓2L�/"c.!' u-('OkjS �1P�T��GKN LEDGEMENTOFCONDIT�ONS <br />T.��...r _ v <br />The undersigned owner/applicant hereby agrees to hold and save harm- <br />less the City of Everelt from any and all claims for damages, costs. <br />expenses, or causes of action that may arise because of installation <br />--���Z�OL7-�ci � 9 and maintenance of ihe i9 Provement or other right-oFway use hereto <br />applied lor and (urther a rees to remove same upon notice trom the <br />isircciio Date Ciry and to replace public properry dama ed thereby. <br />3 �r� Q � <br />FINAL INSPEC N ,1 % � Date � Date <br />Approved as Constructed /// v / h�� eC�e .`c ignature ol Applicant <br />< � —Y WORK AUTHORIZED BY THIS PEFMIT MUST BE STARTED WITHIN <br />everet[ PUBUCWORKSDEPARTM NT iB0 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TC <br />� 3200CedarStreet �y4 �j�t �ti � BE DILIGENTLY PURSUED TO COMPI.ETION.7HIS PERMIT MAY BE <br />Everett WA 98201 � n CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />Phone:259-BB10 � �/� 1` �� � PROJECT OVER 90 DAYS DURATION. <br />t <br />