Laserfiche WebLink
D�!e �1 �i <br />Application For <br />PUBLIC WORKS PERNiIT <br />Print or Type Only <br />Mxiling <br />ity <br />R.7�3 /l <br />f..lr'�\5'�n��rynn-�il/• -_'_ <br />n�nv o�n� • f�l'_��__-- <br />Punnc WnYt ian '�,.� . Q l'i <br />�.�,.� �.. s <br />Lee� �pol Poe PnC � <br />BadncaDun S� � � 0 <br />Gt��— <br />il 29z-116L <br />Phone <br />Ro�n Realty, Inc., dba d& D Builderc• 1429 IIroazlwav. �vErett 98201 252-1166 _ <br />Appllcen' MUling Address City Zip Phone <br />Descrl6e Proposnd Work N°.i Sinale Fami �y Rosi denCe ___ <br />Prolect Address (If knowN �4 - o6th P� ace S E —__ �' "� �` � <br />Atlnch lour (4) con�es o� plens lor piopo�od work � Draw to scale and nele the ,mwwing as epplicehle�. <br />• property Lines <br />• Oulline and dimansions ol all eKistin{� and <br />nronosad structures on the lot <br />• F.zisting and proposed ulilities <br />F'ERMIT CONDITIONS <br />• Cenlerline ol sireet <br />• Indicale No�th <br />• Show any propose.d gradmy chany�s <br />• ShOw measuroments <br />All cnllc lor inspoctinn shall 6e made 24 hrs. m advance - nhono 259•881 5 <br />All worY. 6hqll bo perlormed m ecCordenGe wilh thi5 permit and current Cily ol Cveielt Desiyn nnA Cons�n.ction <br />Slondards end Spocillcetlons <br />Call Lo�:ntion Under{��ound Se�vire 4H hre. helorr• ynu Aiq TOLL FREE NUMBER 1•BOO•424•S.F.$O. <br />Approved lor C�+slruction V / Date <br />�� ' d <br />(� dt�i�],,,rc.�_ �Z;� -- <br />FINAL INSPECTION i Date <br />Approved es Conslrucle f� <br />�,�,�.��q� PUBUC WORKS DEPART ENT <br />� 3200 Cedar Streel <br />Fvcre�� WA 9P201 <br />Phnnr ;59-IIP1'. <br />AGKNOWLEDG[MENT OF CONDITIONS <br />W <br />i <br />�w <br />_ / <br />� <br />O <br />� <br />N <br />� <br />a <br />Th�� undersiqned ownennpphcanl hereby agrees to hold and s�ve herm� <br />ess Ihe Cily ol Evr.relt I�om any antl all claims lor demegas, costs, <br />oKpenses, o� causes ol eclion ihat mey mise because ol instella!ion <br />and mainlenxnce ul the improvemenl nr other righDo��way use hereto <br />:�pplied lor and �urlher ag�ees lo rert.:•�e samn upon nolice Irom the <br />City and to replace public propeity damepeA Ihe�eby. <br />; <br />�- � � <br />�- .<._._ f /,_.-_r _ ,� .� � -.�,� <br />Signature of Applicanl Dele <br />WORH AUTHORI2ED AV THIS PER1dlT MUST BE STARTED WITHIN <br />1BC DAYS OF DAT[ PERMIT IS ISSUED ,4ND ?HEREAFTER IS TO <br />BE DILIGENTLV PU7SUFD TO COMPLFTION. THIS PFRMIT MAV OE <br />CANCFLI Cfl BV THE ::�iV Uf'ON ANY S1f�Pf AGE O� WORK ON THIS <br />pq�'Jfl 1 ���:'f H'�n pt,V; DUI�dIION <br />