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Date <br />PUBLIC; <br />Print or Type Only <br />, - a ..--, � L�'11'�i�'�� <br />An;,lic�tion For �o <br />WOh�(j �ERMIT <br />�,yl <br />V p p <br />� O U <br />��, � �; <br />•• �R N <br />� �� �J"1�.�5�• P.Uf <br />Glu�/� �-�..�e <br />PupM1r.lYvkSPrtrmlla �T/��_L_/ <br />dltln OePI s _ <br />�ubLc WOtk6 Fee p <br />T�I.II i�?C `� <br />Lesi4plL Fn� ���,� .'t. �J <br />]dlan.r Dw .,�i _ L � <br />GG2 :�Z 2 i,lLi /��/ <br />.-� —_. „_, � i.�,_uu,�aa l:rtv �ip <br />Describe �ropused Work <br />P�ojec� Addres's Iif known! _______ ___ <br />A�taeh four (4) copies of plans' loi proposed wurk � D�ac: I:, <br />• PronP-rty Lines <br />�► OvHine and dimensions ol ali exishng �rl <br />propJsetl s(ructures on Ihe lot <br />• Existin� and propo5ed utililies <br />� �-i - <br />Pno�„ <br />Phons —_--_._ <br />�`�-' � �-- W �l..L C:� � 1 <br />_ —C�. � _ 3 x 3olt��� <br />r..i',...c,.� n,:la tha'oila.ving as aoul�cab�e <br />• Genterline ��f street <br />i Ir,�iCaL3 N�r�h <br />! �nov: any r.ronos?d gradinq rhanqes <br />• Sh��.v measu�ements <br />WRITE 6[LObV THIS LIN <br />PERMIT CONDITIONS <br />1. All calls for inspection shall be made 24 hrs. in advance - phone 259-8810. <br />2. All work shall be perlorrned in accordance with this permit and current City of Everett Desiyn and Consiruction <br />Standards and Specificalions. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800-424•5555. <br />�I yaNG• �j/Y/tiGVJ��� ✓�i�/�Z.�! �%�o+'i W � 7!1 �Ll �� � � G�?! y�CrryP <br />/ <br />�./ / , 0 - <br />cP � �/!� � <br />I/!$�/�GI'a��Gt'I Cd.-J �j�DI iY/.��rs vr=,%t <J� ��%;�"GG�� 67 <br />Wr�'' �cr �l�r�c�'Z�w- i�'1 <br />olC �.. '1 •�1•9�f - - <br />__I <br />� I <br />�� ��,�-- 7 � /�-�_ � <br />Approvec�lor Constru,cticn _ p„ „ . <br />Approved as Consiructed � <br />�PUBLIC WOFKS UF.PARTMENT <br />3200 Cedar Sir�e'. <br />Everett WA 98201 <br />Phone:259�fl910 <br />ACKNOWLEDGEP:!ENT OF CONDITIONS <br />Ihv �-n�d�=r,�uned ovmeiiapplican� hcreby agrees to hold and save harm- <br />�ess Ihu Qty o� Evere�� irom any and ail claims for damages. costs. <br />expenses o� causes o( action that may arise because of installation <br />and maintenance o! thr improvement or other ngl���of�way use hereto <br />aPni�ed for and lurther ;�qrees to remove same upon notice Irom the <br />G'�tn rePlaca oubli r nerry damaged therebY. <br />� <br />_�� , G�27-q <br />Siynatur . ol pPl can! Date <br />l4'OP.f: UTHORI2ED BY THIS PERMIT MUST BE STARTED WITHIN <br />�AO DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSU�D TO COMPLETION. THIS PERMIT �9AY BE <br />CANC�LLED BY THE CITY UPON ANY STOPPAGE OF WOFK ON i HIS <br />PRO.IECT OVEA 90 DAVS DUFATION. <br />