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Date � K Z <br />Apn��cetion For <br />RUBLIC WORKS PERMIT <br />Print or Type Only <br />� ua�� Sv <br />Owner <br />* <br />� 1�- U�\ <br />pllcent <br />Describe Piaonund Work _ <br />ra� <br />C1 We-1 I � � <br />Pro�act Addrese (II known) <br />8 q I Y-sG+� <br />Maillrg Adtlress <br />��� <br />l '►�.. <br />PZ w 11�u,��l�m <br />City <br />City <br />.Q 1 �. a-N J. ���� /1 1, <br />�.�r C rt9t — Di <br />- ��� � s+. f� _ <br />9� <br />PuCI�cWnrt�Perm�t� �'3�� <br />9lea Deo� • -_ _ — <br />PuGIK Worb Fo <br />Tol�l {"ne s —"—' <br />Le�� �po� Poe G�m s___ <br />B�bnce Doe S <br />(l�IC(Ef.TEO W/TN EpEU��L <br />�J-e�AY Pf,Pm�; - <br />p��� � 3s��� <br />2iu Phone <br />Zip <br />Attoch foui (4) copies ol plans lor p�oposed work • Drew lo scale and note lhe lollowing ea epplicable: <br />• Property Linea • Centerline ol atreet <br />• Outllne and rlimensione ol ell uxisl!�g and • Indicate North <br />propoaed et�utluroa on Iha lol • Show eny proposad preAing chengea <br />• EKleting end pro0osad utlllties • Show maesuremenls <br />PERMIT CONDITIONS <br />1. All call6 for Inepectlon ehell ba mede 24 hre. In advance - phone 2b9•8810. <br />2. All work ehell be perlormed In eccordence with thle permit and cu�rent City of Everett Deslpn end Conatructlon <br />Stenderde end Speciflcetlone. <br />3. Cell Locatlon Underpround Servico 48 hrs, belOre you dlp TOLL FREE NUMBER 1•800�424•8555. <br />7, J�� �j�tP�uJ %uca7v� �2 yP��C. �QP3S—�'uddcr�as,fff� <br />ca7 <br />� i2 " NA�,�- c�� 4,,,�<� s„��' �..�u;v . <br />.5" �'�.t�.� �.�;.. � � y,�� ii "p�- -� � u`�.�,..0 �`s�i�2 <br />�PUBLIC WORKS D[PARTMEN7 <br />9200 CedBf SirePl <br />Everatt, WA BB?J1 <br />P�ona: 269•8� � 0 <br />W <br />H <br />� <br />� <br />� <br />� <br />� <br />� <br />� <br />a <br />ACKNOWI EDGEMENT OF CONDITIONS <br />Tho undereignod awne�/eppllcant hereby egrees to hold entl seve herm� <br />less Ihe City of Everert i•nm eny and ell clalms lor demegas. costs. <br />ezpenses, or causes ol aCtlon thal may mise beceuse of in�tallation <br />vnd maintenance ot the hnpro $manl or other righl-ol�way uae hereto <br />epplied lur and lurther agree 60 �emovn aeme upon notice Iro�n ihe <br />CitY and to replace publir, pro arty damege thereby. <br />i���-��, �� � / �-/� <br />Siqnature ol .4pplicanl DatS <br />WORK AUTHORIZE� B'f iHIS PERMIT MUST BE STARTED N'IIHIN <br />180 DAYS OF DA�E P�=RMIT IS ISSUED AND ?HEREAFTER IS 70 <br />BE DILIGENTLY PURSUED TO COMPLETION. TH`R P�qMIT MAV BE <br />CANCELLED BY THE CI�V UPON AtiV STOPPAGF OF WORK ON?HIS <br />PiiOJECT OVER 90 DA'iS DURATION. <br />