|
Date s' � �
<br />L_ �r� -� �
<br />Applicatio� for
<br />PUf3LIC WORKS PERMIT
<br />PrintorTypeOnly �, !1' r0ST1N" AP�
<br />PUEirt Ww�� Pmm� • �'I i� / I L li'
<br />Bvlp �aot • �' �(') ''
<br />PuohrWor�� fre
<br />Toiu im f
<br />IwMe�Du �nePUU s
<br />Mlance0ae_ i ,-ii' '
<br />, , i, �ici�„er� lUill ,.vcr��,rr�r, 1.,. .. ,4 . .. 1 .i
<br />Owenr ' .� Meiling Atltlress � Cily � r,� Zip Phone ��
<br />. a i. �
<br />� � -
<br />� .'f r .. . . ' n
<br />Appfitent Meiling Atldrees City 2ip Phone
<br />Describe Proposed Woik
<br />Prole�� Addrese (il known� !� � � � � l��!� �.-i1 ��) � E _
<br />A:lach lour (4) coples ol plans for proposed work � Drew to ssale anA note ihe lollowing as app�icable:
<br />• Property Lines • Cenln�line ul9freet
<br />• Oullina and dimpn6ion9 0l ell e�isting anA • Indicale Norlh
<br />propoaed struclwec on the Io1 • Show eny proposed g�eding changes
<br />• E�i9ting qnd propCsed ulihtie9 • Show measurement9
<br />PE7MIT CONDITIONS
<br />1. all cal�s lor Inspectlon ehell be mada 24 hre. In edvance � phonc ?59•881 �.
<br />2. All work ehell be peAormed In accordence witn thla pe�mll end currenl City of E.eretl Design and Conetmction
<br />Stenderde and Spacllicetlona.
<br />3. Cell Locelion Underground Service 48 hrs. before you tllg. TOtL FREF NUMBEN 1•BOO•424•5555.
<br />i�.,�, -�„ �� ��I°,i I,.. I ��m.l�.ipni •I:,�G l�� � ino•.� .�. �i� _.� �.
<br />di,�i� � loi i.Wu �4�u{� �i iu d tic�itlll:�� i�i� deni111hL,��
<br />' ; r..j� .u,. re�t• .Irnm m �ll tmw<
<br />� mb pmcr mid s�dewelk N u�e plw n� uew v,� ,�� �,.
<br />h��r�unn of16e ('nhllc u'crks luapecra
<br />�m rhxnde �n ifir dmrw+N ���� �m��� n� ��p�,�� �, i� �
<br />,p���u Nidih
<br />� �dju t H:,!.�i Loee: !o rrsde ut end of ;nu.<tni�u�
<br />'+ ;�tli ten�,s enR nr � Ibtr -�n���n �onhol meexm� r; i• •�
<br />�a����, ��.������
<br />, . �i .�.i .,�,� ��� , � �.
<br />��. I11: �1 � ! i I il: i '1 '�
<br />� , ,, , � ,,. � ��. ,
<br />�� i' ,.. , ��ni., -i, �, �.i�n ,�. i�, . . ,
<br />W
<br />�
<br />�
<br />�
<br />O
<br />�
<br />�
<br />�
<br />a
<br />in_ RnnRup r' r9r,r �„11 he d'aCh01�'rl' �
<br />� Ot3 t ft K � �ttll!'�`t 10 UIC �1I8Y5 .y611f1 [bN�l �.N'�r•. n iii� �, � � n lir '�.,i�. .� .�,: i..�
<br />' � JI. � • � � :. �) � �OIII1CCt 10 f��." IGf'. Ilul1.9'I�, :; I. i, I;i�. , �. . .. .
<br />A�KN6W{.ED�EM�F�1�T OF CQjJQ TIQNS
<br />�, / w�Uina 1 mr � un ;�,. i�� �:�� , i � i�� � � n Ir �..�.0 �n.� i
<br />�• The undersigned owner/npPhcanl hereby egraes lo hold end save ha�m�
<br />less Ih�a Ctly ol Everetl Irom nny end all claims lor dameges, cosls.
<br />1 ezpenses. or cnuses ol ec�ion thel mey erise because of inslallation
<br />�C��I" /�/! `�� �, i r— and maintenence of Ihe improvemenl or other nghPohwey use herelo
<br />CL t r apphed for and lurther egrees to remove aeme upon notice irom the
<br />Approv for Construction Dale C�ly anA lo �eplace pubhc property damagetl fhareby.
<br />�r�_ „_, _ 3�7��L
<br />�I AL INS E l0 � Date
<br />Appioved as Conslructnd
<br />�PUBLIC WOHKS DF��ARTMENT
<br />3200 Cnder S�reel
<br />F.vero�l WA 98201
<br />Phona-.253�8810
<br />t, <. '
<br />f' f. � ��. ,��. -
<br />Sign,ilure ol Appli0En1 Da�e
<br />WORK AUTHOFIZEG BV THIS PERMIT MUST BE STARTED WITHIN
<br />180 DAVS OF� DATE PERMIT IS ISSUED AND THEREAFTER IS TO
<br />BE DILIGENTLV PUI�SUED TO COMPLETION. THIS PERMIT MAV BE
<br />CANCELLED BY THE. GTY UPON ANV STOPPAGE OF WOfiK ON THIS
<br />PROJEC f OVER 90 DAYS DURATION.
<br />
|