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/ <br />Date ���' ` <br />Applicai�on For <br />PUBLIC WORKS PERMIT <br />Print or Type Only <br />Lrs� �1�vcr>> ,';�o �.�o��F� <br />m F' <br />ApPlicant <br />Mailing -�.i�iress <br />Ci�y <br />-, . , <br />I'.�te�.lA'unvPnrm�i� _L�%.�Ll � 4 _ <br />f3i�]N f)ePl ♦ <br />P�dn�c Wm�efee s <br />lO1R� f II! ! <br />I �'S5 AI�IiI 1�1•� r11��1 i <br />11,ii,�i„ r.l1�i�. �' �.'�i ��` <br />�,r= r��- f�� rr ,,s.��,� :�. ;r-;, <br />zip P�,onc <br />Prolect Addres� 111 known) L� f F� ST" n F /`i !.'o f.�� /Q. c[�{/�c,�� _��—�__�--' <br />Al18th lou: 14) copies ot plans lor propOse7 work • D�aw tu scale and note Ihe lollowing as opplicable� <br />• Proprny Lines • Cenlerline of st�eet <br />• Outlin0 nnd dimen5inn5 OI all cxisiinq inrl • InAiCate North <br />prcposed slructures on the �u • Show any propo:ad qrading changes <br />• 7.K�sting and proposeA utildies • Show mea5uremcnl5 <br />PERMIT CGNDITI� ' S <br />�. All calls lor inspection shall be made 24 hrs. in advancu �� �one 259•881 5. <br />2. All wo�k Gh011 be pe�lOrmod in ac[ordanGe with Inis pem�� and currrnt Gny ui lvr •tl Design and ConsVucuon <br />Stentln��� and Specilicatione. <br />3. Call Locat on Underground Ser�ice 48 his. beloru you dig TOLL FREE NUMBEP 1•800•424•5555. <br />-� �t%t�,.(:—.�-�tZA�.tl61 Qr� �" LIY1JiI/.fJEt -� <br />� G�iP,a..v,4b6 /S �vU/ To d'F ��'�c>r.cf-, � i%c�c �s-t -� �c <br />/'✓EC'Fss�,�j/ i�.f�E �� FtiSrs��cF.t� <br />.5 f%c G/�?P: G-:e��vL /S To �E � GE.'9.�i -`�E • C./' <br />L'ic'G•i7iv.� i-»l�i�:V.P� .'',.,ii l.-l<'.(•�G ��CAC.f'S ��F G'C.'�.'f7L° <br />L%i`' /�� �'�.�Q� �. . <br />lor <br />s/ <br />G. <br />fINALINSPECTIUN � <br />Approved as Conslructgd <br />�.�y����� PU6LIC WORKS DEPARTMENT <br />� 320� ::edar Sheet <br />[verelt. WA 9H2O1 <br />Phone�.259�HB15 <br />W <br />� <br />_ / <br />ACKNOWLED3EMENT OF �ONDITIONS <br />ihi� urdersigned owner/appl�cant her�bi edroos to hold and save ham,� <br />ie;s the Cily ul Everelt Pom any anv �II claims lor domages, cost;. <br />c.penses, or causes of an�on Ihat rr.ay arise because ol installa�ion <br />nnd malntenance ol Ihe im: rovement ar other ri9hbol-way use hereto <br />nppl�od lor nnd lurther ay�r�s Ir remove Samc upon notiCe Irom the <br />Ci1y and lo replacn public pmpertv da���aged ihereby. <br />' 6, ,� _-- s.,�-�- <br />'iqnaturc of Appllcant Dale <br />WORK AUTHOHIZCD 81� fH15 P[RMIT MUST BE STARTEU WIiHIPI <br />100 DAY,i Of DATC PEfiM1T IS ISSU[U AND THEREAFTER IS TO <br />E3E DILIGENTLY PURSUED TO COMPLETION. TNI ; PERMIT MAV �P <br />CANCELLHD RY THE CITV UPON ANV SiOPPAGE OF WORI<ON TI Jti <br />PROJ[CT OVER 90 DAVS OURATION. <br />