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Date�� �uM r Wrv�s ae�mil• <br />' -��-�-_ <br />� Applicat�on For n�nu nnoi • _ <br /> PUBLIC WORKS PERMIT �°^°°~'°��•F°° <br /> I iolaiFer s — <br /> lres Rppl Fee Pai� s <br />� 6n�a�re Oue S <br /> F'rint or Type Only <br />' �'�� h� nr� i�%� �+�� ' ' ' � -�� r� ���r�� �-I �-4i9�� <br /> �I`� ��l 11Y �t S��L� � � � <br />� Owner Mailing Address City Zlp Phone <br /> =yt lMG <br /> Applicant Mnilmg Address City Zip Phone <br /> /� � 11n"" ny� I 1/ <br /> Desc�ibe Proposed Work l_/�� - '� (���Y_ — <br />� Prolect Address�if knownl � <br /> � <br />' Attech lour�4)copies of Dlans for proposed work� Draw to scele and note ihe following as applicable: � <br /> � Properly Lines • CFlnlerllna ol slreet � <br /> • Outline end dimensions ol all exisling and • Indicete No�th <br />' proposed alructures on the lot • Show eny proposed gradmg chenges <br /> • Exisling snd proposed u�llities • Show mensuremenls � <br /> I DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> i 1. All calls lor inspec�ion shell be made 24 hrs. in advance� phone 259•88�b, � <br /> 2. All work shall be performed in acco�dance with this permil end curreM Cily of Everelt Desigr. and Conslructlon <br /> SfenAerds and Specilicalions. <br /> 3. Call lccellon Underground Service 48 hrs. balore you dig.TOLL FREE NUMBER 1•800•424•5555. � <br />� r�1L�t VzC-�-�i � � <br />' ��a; <br /> �i-�f H <br /> � <br /> O <br /> a <br /> i <br /> A:HNOWLEDGEMEN7 OF CONDI710NS <br /> The unda�si9ned owner/applicant hereby eg�ees to hold and save harm� <br /> less ihe Cily of Evereft Irom eny end all claims for dameges. costs, <br /> expenses. or ceuses ol ac�ion Ihat mey erise beceuse of inslalletion <br />� end maintenance af ihe �mprovemenl o� other rlghPol�wxy use nereto <br /> applind lor and further .yiees to remove same upon notir.r, Irom ihe <br /> Approved lor ConatruCllon Dete ���y�nd to repixco puhh�, proPer�Y �ima�ed �hereby <br />� FINAL INSPECTION Dete — -- — ------- <br /> App�oved as ConsL•ucted S�gnature ol Anpin;ont ���� <br /> ���.�P�� PUBLiC WORKS DEPARTMENT WORK AUTHONIZED BY TNIS PERMIT MUSi BE STARTED WITHIN <br /> 180 DAVS OF DnTE PERMIT IS ISSUED AND THEREAFTEP IS TO <br /> � 3200 Ceda�Street BE DILIGENTLV PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Fvere�l.WA 9A201 CANCELLED BV Tf1E CITY UPON ANV STOPPAGE JF WORK ON THIS <br /> Phone� 25?�flA15 PROJECi OVER 90 DAYS DURATION <br />