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Date � � �i � <br />i� , <br />, . 'cation For <br />PU�LIC V�iOI�KS PERMIT <br />Print or Type Only <br />, <br />�6 ,�OC�- 8����'IL <br />lin9 Hddress ���Y <br />linr� Address City <br />Describe Proposed Work Q^'"" y C�`""`�r' �D <br />Publlt Wa�Ns Permi� • o y I,� <br />Nm;� oeat . y 'a � - <br />Pu�llc WoikSFeo y, ?��� �n p <br />Tolal Feo <br />LessAp01. Fen Paid 5 <br />I'�]�1J. 00 <br />Balancc Ouo � <br />���r(�, �� .3,5 � �� ����� <br />?ip Phone <br />��n Phone <br />Project Address (if kno�vn) ° � — <br />Attach tour (d) copies of plans (or proposed work - Draw to scale and note the follo�ving a; appllcable: <br />P <br />• Property lines <br />• Outline and dimensions of all existing and <br />proposed structures on lhe lot <br />Y Existing and proposed utilities <br />• Centerhne o stre_t <br />Y Indicate North <br />• 5how �ny proposed gratlin� ch:�nges <br />• Show measurements <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advanee - phone 2b9-851 S. <br />2. All work shall be pertormed in accordance with this permil and currenl Ciry of FvereU Desi9n and Construction <br />Standards and Specificationt. <br />3. Call Location UnAerground Service 48 hrs. betore you dig TOLL FREE NUMBER 1•800-424-5555. <br />� Cjara}2 Goot 5 d-u� Cv.larSe�Y G�ar c�3 C w.�n'a4- �i eG So...a:���� <br />� �-3� W'i��l1e- 2XlS�IH` AY��e�.vQ� • t� S0.r4qE C�Uo�i <br />J 1 �P�--t' J.� �W..{ 'LUSi- <br />pi �Ui�JP�ti+n� cc. C�e+S � � S`1T �. <br />S,dz ��' � l.n��s.� ,5 �����:.-�� <br />-- ��- �/i� -�- <br />pproved for_Cons�nn Date <br />d1 /l � <br />13N� ^ � � <br />FINAL INSPECTION Date <br />Approved as Conslructed <br />everett PUBLIC WORI<S DEPARTM T <br />� 3200 Cedar Street <br />Everett, WA 98201 <br />Phone:259-A815 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />�.: <br />The undersigned owner/applicant hereby agrees to hold and save harm� <br />less the City of Everett trom any and all claims tor damages, costs, <br />expenses, or causes of actlon that may arise because of installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agrees to remove same upon nr!ir.e �:^T the <br />City and to replace public properry damaged thereby. <br />��t� ,���,�._, s-�i ���y <br />Signalure of Applicant "'�e <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STNRTED NlITHIN <br />iB0 DAYS OF DATE PERMIT IS ISSUED A�dD THERFAFTER IS TO <br />E3E DILIGENTLY PURSUED TO COMPLETION. THIS PEf7MIT MAY 8E <br />CANCELLED BY THE CITY JPON AtJY STOPPACE OF WORK ON THIS <br />F�OJECT OVER 50 DAYS DURATIOW. <br />z I <br />0 <br />� <br />.. � <br />ml <br />�+ � i <br />—i -n � <br />