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Date�LL� � �' � <br />Application For <br />PUBLIC WOR'CS PERMIT <br />Print or Type Only <br />/ 70/ � , <br />Maihng Atldress <br />Mailiny Addrr,ss <br />Pue�rc WaFePermn ��"�� —'_- <br />Bina Deot • 1�-�� _--_ <br />auei¢WarheFeo ` <br />loleiFee <br />Lee> Aop� Poe Vai� s_ <br />B�isnce Oue 5 Q <br />�� <br />;�09 �y <br />�lit' .5�., A`k �� 6'i 5 s <br />C�ry Zip <br />� <br />3l 3 �:�3/C, <br />Phone <br />Pnone <br />Desc�iue Proposed Wark C ���E�T S�iG'' — <br />Proiect Address pf known� =�U� — <br />Atlach lour i4� coryns ol plans lor p�oposetl work - Draw to scale and nole Iho lollowing es epplicable <br />• Property Llnes • Centeiline of sireet <br />• Outllne and dimensions ol all existing end • Indicate Nwth <br />pioposed slruGtureS on Iha lot • Show xny pwposeA qrndmy chanc7es <br />• Exis�ing md proposed uDlities • Show messuremenls <br />PERMIT CONDITIONS <br />1. All c9115 �a inspection shaii :.^ maJe 24 hB. in Bdvnnce � phone'1S9•BSii S <br />2 All work shell be perlo�metl in accordenca wl�h thic permil and currenl City ol Evcretl Design Flntl Conslruction <br />Standerds end Specificetions. <br />3. Call Locatlon Unoergrountl Service 4B hrs. 6elorx you diq. TOLL FREE NUMBER 1•800•424•5555. <br />� �X�SriNG Si�F<✓QG.C.r' ��'� <fN.Ci�'QtE;�/ (�,�/� i,c! <br />/vEl.[� �Oii/D/riO�c% ��E LI�I�L /C�ji � ,PFd�+viieEO TG <br />�E"i'Lec6 A�/y -s'�C-c✓aAc- Llt,ssfl�rFo �G.Pi,vG C'avSrh�r'Tiet/ <br />5' ,Pp�� OL'Ld.c� S�c>UTs� AeE Tb �E Tir�N.-_G.-,r/Fv To <br />��sr�.vc, !'u,ed a,ea,.vS. <br />,l^. A�/r G,feOi�e�l- � T.rF Le•�T /S Te� 6'F �� �n.i� St AS <br />,f.'cT Tc /Mf',dC.T %HE S�'.eecri,vi�..�C- LaiJ C,vi:.v <br />,�'A�n/ - k/ATF:2 .t'v,r/- ��.Cf: <br />�1 �G �LlL � /�,�[+D�"'' % � �� L <br />AppwvPd fd ConSVuCUOn Dale <br />�n ! <br />�, � � _ � � <br />FINAI INSPECiION ete <br />Approred ns Constructed <br />i.��.��.�� PUBLIC WORKS DEPARTM[NT <br />C� 3200 Gedar Streel <br />Eeeratl. WA 9A2G1 <br />Phonc 2ti9�fl81Ci <br />� <br />� <br />O <br />a <br />ACKNCWLE�GEMENT OF CONDITIONS <br />1 h� unArrs�<anPd owner/npphtail herehy a�rees lo hold ond save hann� <br />less ILe Cily of Evorelt Irom eny ni�d all cleims lor damaqes, cusls, <br />Fxpenses, or cau5es o� oction that mny arl5e ber,ause nf instai'atio�� <br />onA maintenence ol �tie impiovemenl or other nyht� �Fw;iy us�� herrin <br />ppphCd br And lurlhe� egree5 to rBmove SBme upan nnuar hom IhB <br />C�ty and to replsce puhhc property damaged Iherehy <br />�'�I.IFLQ ��j]J- ,iA`.# �Y�R� I( __' � i l " r� <br />S�9nntwe ol Applicant U Dale <br />WORK AUTHORIZ[D BY THIS PERMIT MUST BE STARTEf1 WITHIN <br />180 D/\VS OF DAiF PEf7MlT IS ISSUE� AND THEREAFTEf1 IS i0 <br />BE DILIGENTLV PUPSUED TO COMPI.FTION THIS PERMiT P�A1' B[ <br />CA�JCELLFD B`' THE CITY UPON ANY 3TOPFAGE OF WORK UN THIS <br />1'RO-ICGT'�VEF 90 DAYS DURATION <br />