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i <br /> i <br /> � <br /> � <br /> I <br /> Date��d f�mi,cwn��nrr�m(n�.� �?�_���_ <br /> APPIIf.811011 FOf P�i14 Di : � _�i.G��___"— <br /> PUBLIC WORKS PERMIT -----�°'� <br /> aui,i�c wnrre'en <br /> To�el Fae s! - I <br /> lPSS�p111 {EP I�d�11 i �n I <br /> Bn�nnceDi�r S�%(���� . <br /> Print or Type Only =- <br /> GPohPrrn .�KL lQl4 • /1N 3�/'``` '�3oa 5���+�`lle 9d'�o3 Sy7�a13 <br /> pwner ldailing Address C�ty Z�n Phone <br /> S_Ty�k- <br /> Apphcant Meiling Address City Zip P��one � <br /> DescribeProposed Work __ A/Prw/ S� n����_yyLj��-Qi_�.r.{1 .N �Pn�nl n _ <br /> �.-..� <br /> Pro�ec�Address lil knownl �2� � �d/� ��-�� __ � <br /> � <br /> Attach four(4)copies ol y,ans lor proposed work � Diaw lo scNe nnd note Ihe lollowing ns�ppficEble�. � <br /> C P�ope�ry Lines • Centerhne ol street ,tw <br /> • Oulline 3nd cimen5ions o�all eMishng nnA • Indicale Norih V♦ <br /> pr�posed slructwes on Ihe lot • Show any p�opose9 yridin� chTnyes <br /> ! Eeisting end proDoSed uUldies • Show measuremen�s � <br /> DO NOT WFITE BELOW THIS LINE <br /> PERMIT COND!TIONS O � <br /> 1.An ceh:for irsoection shall be made 24 h�s.in advence�phone 257•8810 <br /> 2.All worF shr.11 b�a peAormed in accordance with this permil and current City ol EvereH�esign and Consiruction � , <br /> Standartis and Soecificalions. <br /> 3.Call Locatlon Unc:e�ground Service 48 hrs.belore you tlig.TOLL FNEE NUMBEq 1•@00•4L4•5555. � <br /> ,! .fiiJl Cilyd���;f=: l!J I11I�: DI� [VL�.b1fiY C�_�f h�U; l Uf. i1( I�I;11VI:f� � <br /> C�1' 1HE I-'IIHLII 140RI�-:S DfF'hRTl9f�.Ni . <br /> 'i .USL PUI!I_IC DF�AINAGE i`(:iTEt1 !1'.i PFOVIDED FOFi D(��•1l�C:if nIIT'_;. <br /> ..FIN�' L(7i GR/ll)1= CFI(1NGES MUST F�E /1PFROVFP !n' ITIF � ' <br /> �"`IIFIL.IC IdCJF<k�i `NSf'G'CTOF'. ' <br /> ` � ' � � 1 I ',' :l (I;fT I '�. f I F�(1PJ �lT Cil I ' iF�CS. � <br /> � <br /> O i <br /> a <br /> ACKNUW'LCDGEMFNT OF CONDITIONS <br /> The�indersiqned owner/applicant hi•reby agrees to hol�i�nd save harm- <br /> less Ih�� Cdy ol Fvereu Irom any and �II riaims lor tlamages. cosls. <br /> � / /� / � etoensns. oi causr.s ol nclion �hat rnay nnse beCause ol instadilion <br /> ���L�Y��" '��� and mai���enenr.e ol the impiovPmenl or oiher nghlrof�weY use hereln <br /> npMied lor and furlhe� FlgreeS lo remove sanie uUon nolirr. Irom tha <br /> ApprovFd lo�Consiruclion Date Cily and m replace public property damaged Iherehy <br /> � '�`/'�,��/J�/"����;�� -, , _ <br /> � .��-/ ..�s�:= , :��,. �.� � ���- <br /> RNAL INSPECTION--�5��� - Dale . � f�� — <br /> Approved as Consiructed 6ignelwe ol ACPlicnnl / Dnte <br /> rvvrrtl PUBUCWOPKSDEPAFTMENT WORK AUTH0171ZEU BY THIS PERMIT MUST B STARTEn WIIHIN <br /> � 3200Cetlar51,ee1 180 DAVS OF D�TF. PERMIT IS ISSUED AN� THEREAFTER IS TO <br /> EvereO.WA9R201 GE DILIG[NTLY PURSUED TO COGIPL[TION. TF�IS PERMIT MAV BE <br /> Phone 259�9P10 CANCELLED BV THE CITV UPON ANY STOPPAGE OF WOAK ON i Hi5 <br /> r�o,ircT ovrc� o0 onvs nunnnori <br /> � <br />