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�B�Q��^�� Pue�ic warMe Permq• S���—/�� <br /> APPHClf�IOn Fo1 Bl�p OePt • ��/(l-�—s U V <br /> PUBLIC WORKS �ERMIT °°°;o„FeeFae s <br /> lee��pD�fer PeN s <br /> Print or Type Only BelenceD�e $��� <br /> — �v� ` ,3=� 5���.2 0 <br /> /��,?/— //�3 r�sJ'� ���' lc%/9 <br /> Owner Mei�ing Address City Zip Phone <br /> �l� '/� <br /> Appllcant Melling Adtlress City 21p Phone <br /> Descnbe Proposed Work _ ' v� Qf.J ��� <br /> — � --___ � <br /> Pio�ec!Ahd�ess�il r;nown) 3os- /�i9 �ST_ .$;F _ _ � <br /> Pltech lour(4)copies ol plans for proposed work- Orew to scele end nu;^the lollowing as applicablc � <br /> • Property Lines • Cantarline o�sireet � <br /> • Outhne and dimansions ol ell existing and • Ind'calr Norlh <br /> pwposed slructures on fhe lot • 3how eny proposed graAin�chan�e5 <br /> • Existing entl proposed utililies • Si�aw measureme�nis � <br /> DO NUT WRITE BELOW THIS _INE � <br /> PERM17 CONDITION3 <br /> 1. All �alls for inspection shnll Ga made 24 hrs. in advance� phone 259•88�5. � <br /> 2. All work shall be performyd in accordance wilh �hi� pe�mit and cwrenl City ol Everelt Design end Conslruction <br /> Slandnrds nnd Specilications. <br /> 3. Call Location Undergrountl Sorvlce 4B hrs. belme you dig.TOLL FREE NUMBER 1•800•424•5555. � <br /> 4. ANY GFtADING DONE ON THIS (AT SHALL RE DONE �0 AR NOT TO IMPACT THE O <br /> SURROUNDING LATS WI?'H RAINWATF.It RUNUFF. <br /> 5. '�NY CURB & GUTTER OR 9IDEWALK DAMAGF.D DURING CONSTRUCTION SNALL BE � <br /> REF;,ACED B'L THE APPLICANT. <br /> 6. D�7WNSPOUTS FROM THE HOUSE ARE TO BE TIGHT-LINED TU THE DRAINAGE SYSTEM. � <br /> 7.ANY ORGANIC MATERIAL ON SITE TO BE BURNED OR HAULED OFF WI'PH PERMITS. O � <br /> li <br /> ACKnOIYLEDGEId[N1 OF CONDITIONS <br /> The undersignPtl uwner/apP��cant hereby agrees fo huld nnA seva haim� <br /> � less Ihe Ci�y ol Eaarett Irom any and xll cleima for damages, costs. <br /> ezpenses. o� ceuses o� action that mxy arlse because ol in�tallation <br /> �� ��_ [� !� r,�� nnd maintenance ol the improvement or other nghhoi�H�ay use hereto <br /> � Applied lo� and lurlher egrees to removn snme upan ncl�ca i�om ihe <br /> Ap�rrovaA lor Cons tlon • Date <br /> Gty xnq to ace p Ilc property damaged ihereby. <br /> . � ��� � � -� <br /> FlMAL INS ION - Qale <br /> AnProvcdasConsl�uclei � pnature Applicant Date <br /> cvrretl PUBUC WORKS DEPAHTM[NT WORK THORIZED BY THIS PERMIT MUST 9E STARTED WIiHIN <br /> � 3200 CeAa� S�reel I80 DAVS OF DATE PENMIT IS ISS.:°D AND THEREAFTER IS TJ <br /> Everolt,W!� ��8201 9E DILIGENTLY PURSUED TO COMFLEi 7N. TNIS FERMIT MAV BE <br /> Phone: 25��PB15 CANCELLLD B'i TFIE CITV UPON ANV STOPPAG[OF WORK ON TNIS <br /> PRO.IECT OVER 90 DAVS DURATION. <br />