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� �� <br /> C�H <br /> H � �MC <br /> �y�r-"i Date��/ ; � r' ' aom���wo�x:a�,mn. �� <br /> �5�3 Application For em¢D�o�.•. 9�TpZ�/ f G� <br /> � �d PUBLIC WORKS P�RMIT P°°°°�YO1M5FeC - <br /> O H tmal Fae $ <br /> � �J(� Less ApoL Fee PaiO $ <br /> Qy � 9alanceDuo S_ <br /> zy�.y Print or Type Only <br /> t"y <br /> �y H .l p <br /> �0,� C V�i .r'� �l?IYN IOaaD 'l2�,?11C� LM .TJ�� Ft/�/� CJ.O ZP'� — <br /> � Owner � Mailing Atldress City Zip Phone <br /> �H� S t_ <br /> -y��- Appli`ca t Mailing Adtlress City Zip Phone <br /> � Oescri6ePropasedWork QooY PUer pY,1rr•�A�G ,(�/7/�7fD�� d N�/7n/ (.([(��� /'A�C� <br /> Frolect Address!if kr�own) � nQ����$� �,1 .�� _ � <br /> � <br /> Atlach four(4) copies o�p�ans for proposed work-Draw to scale and noie the tollowing as aGP�icable: � <br /> • Prooerty Lines • Cente�line d streel /w <br /> • Outline and dimensions of all existing and • Ind�.ate North V, <br /> proposed strucNres on Ihe lot Y Shnw any proposed grading changes -- <br /> • Existing and proposed utilities • Show measuremenis � <br /> I I JO NOT WRITE BELOW TI115 LINE O <br /> '�.' PERMIT CONDITIONS <br /> 1.All calls for inspectioo shall be made 24 hrs.in adv.nce-phone 259•$810. � <br /> '�� 2.All work shall be performed in accordance with this permi;and wrrent City of�vere!'.Design and Cunsiruction <br /> � ' Standards and Specifications. <br /> � <br /> 3.Call Location Underground Service 4tt hrs.tefore you dig.TOLL FREE NUMBER 1•800•424-5555. � <br /> 1 �/�n - , � ' �� <br /> ' / v��w, rdm_/'2 /.X��»vc.7C ��'n7� /���,x� O <br /> �_i ��;� H <br /> �� �� ?�;_ 9� � <br /> �' O <br /> -� a <br /> - <br /> ' f ACKNOWLEDGGMENT OF CONDITIONS <br /> , The unders�9ned ownedapplicanl hereby agrees to hold and save hanr� <br /> - less the Clty ot Eve�elt irom any and all claims br dama9es, r,osts. <br /> ezpens=s, or causes of action ihat may arise because of installation <br /> and ma�ntenance ol the improvemenl or other right-ol-way use he•eto <br /> applicd for and lurther agrees to remove same upon notice Irom the <br /> Approved for Construction Date City and to replace public pmperty damaged thereby. <br /> FINAL INSPECTION Date <br /> Approved a5 Construcled Sic�nalure ot AppliGan! Date <br /> ��r� PUBLIC WORHSDEPARTMENT WORK AUl'HORIZED BY THIS PERMIT MUST BE ST.4RTED WITHIN <br /> 3200CedarStreet 180 DAYS OF DA7E PERMIi IS ISSUED AND THEREAFTER IS TQ <br /> EveretL WA 98201 3E DILIGENTLY PURSU[D TO COMPLETION.THIS PEFMI7 MAY BE <br /> Phone:259-8810 CANCELLED BY THE GTY UPON ANY STOr'PAGE OF WORK ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />