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Date a K ?� <br />ApPlicatlon For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />S,m;�-�� � ql y-.s�G� PZ l,� <br />Malling Atld�ess <br />.�<<tAa.rs S4�1 � <br />Describe Proposed Work <br />Alalling <br />i r�S'�b-Q.Q, r <br />Prolect Addrosa (if knnwn) /U { � <br />�� <br />n„m�c wo.w, ae,mn . 7 .3J�2 <br />BIUp DaO� � <br />PuoiK Wor4� Fee <br />tol�IFaa s <br />La��Appl Faa Vutl S <br />B�i�ncs0ue S `� <br />/_iJCtfcrEO [,��rr <br />��U,�c l�'m �� ����v <br />-- 1 r? J i <br />�V ZiP f�hr <br />cny <br />� �- e�-r�. 12 " <br />Atlech four (4) Copies ol plene lo� proposed wnrk • Drew to aCale end note Ihe lollowing as applica6le: <br />• P�Operty Linea <br />• Outline and dlmenslona of all existinp end <br />proposed atrucfure9 on Ihe lo� <br />• EMlating and p�oDosed uliiities <br />• Cenlerline of streef <br />• Indicete North <br />• Sh�w eny proposed fl�ading chenges <br />• Show measuiemenls <br />EA.zt ir,L <br />v�R�,.,- <br />,� � � <br />Phone <br />PERMIT CONDITIONS <br />1. All calls for Inspection ehall be made 24 hrn. In advence • phone 259•8810. <br />2. All work ahell ba peAormed in eccordance with this pe�mit end current City ol Everetl Dealgn �.nd Constructlon <br />Stendar�a end Speclllcatlons. <br />3. Cell Location Underpround Servica µ8 hrs, befo�e you dip. TOLL FREE NUMBER 7•800�424•5555. <br />�, f� �ta�nr�r,e� %u�'�e /2 �/.ol�C. ��3P�S—,�vd6[r9asf�� <br />02 �Z �� �iA�c Co'h 4, a,�%Ql��t� Si.•n�i /-.�c�iv _ <br />-S �'�r`c•C �'��;., -�` � y�o� A "p�- •e � �`..�� "�`f�o2 <br />� �' = �i- <br />Approved lor Cons4 clion Date <br />FINnL INSPECTION <br />Ap��roved as Consiructed <br />��/'�� PUBLIC WORKS DEPARTMENT <br />���f-1 3200 Cedar Slreet <br />��r Evere�L WA gB201 <br />Phona:259�8810 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />W <br />� <br />� <br />� <br />� <br />O <br />� <br />� <br />0 <br />a <br />The undersigned owner/applicent hereby agrees to hold and seve harm� <br />leas Ihe Clly ol Everell M1om any and all clpims lor dameges, cosls, <br />expensfls, or ceuses ol action thel may arise beceuse ol inslellalion <br />and meintenance of the improv,ement or other right�of•way u5e hereto <br />applied for � id lurther agree� to remove same upon notice Irom the <br />Ciry and to rn,.lece public pro erty demage theroby. <br />'«z�� � /-3 - yz_ <br />Slgnature ol Applicant Date <br />WOFK AUTHORIZED BY THIS PERMIT MUST B[ STARTED WITHIN <br />180 Df.l'S OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILICiENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BV iHE CITV UPON ANV STOPPAGE OF WORK ON THIS <br />PROJEC70VER 90 DAYS DVRATION. <br />