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D a t e '� ��`' �� <br />Applicabon For <br />PUBLIC WORK$ PERMIT <br />Priiit or Type Only <br />��Y!�ti 5 <br />��.,i„� �e,:,., ro,m�� .� �� � -. <br />a��� ���,� . � y/— �j % _-- <br />n�o�m wo�x� fee 6'}O. C7 O _ <br />Tal�l fee <br />L•esAO�IfeePeids�— — <br />❑a�.a �r.n Oue S a'�• O O� <br />�9�/� <br />npn�icanl <br />Describo Proposod Work <br />Meiling <br />U- <br />Zip Phcno <br />_ --� � �-��-� � S�, _ <br />Pro�ect Address (If known) <br />tl� <br />Aitach lour IA) copies ol plans lor proposcd work <br />�raw to scnle and note Ihe lollowing as apphca ��. <br />• Proper�Y Lines <br />• Ou�line and dimensions of ail on�si�np anA <br />proposed strudures o� �he lot <br />• Existin3 and proposed utllitie� <br />• Cenlerline oi street <br />• Indicate Morih <br />• Show any propo5ed gradml7 �hnnges <br />• Show mensuremr.nls <br />PERMIT CONDITIONS <br />1. All calls for inspecuo�.i shnu he matle 24 hrs. in advance - phone 259•881 5. <br />°. NI work shall be p�����ined in accordance wilh ihis permd and cunont City �I C���'<<'�� ���'S�tiln and Coi�;Irucl�nn <br />Standnrds and Spec�licat�on;. <br />;1 Call Locatiun Undergrow�d Service 4B h�:; �i"���'�' Yo�� dig TOLL FREE NUMBER 1•BOO•424•55 . <br />�, 5 /I 't� I <br />, '; 11 _1C._�.,_-- <br />Appi�vetl�orGonshucUon <br />G.�tc <br />�b�L —� 3 -,2�_. <br />��� o,��� <br />FW4L INSPEJTIJN <br />Apn�ovad ns ConstructrA <br />�,`,i,,�.�� PUBLIC W(JHKS UEPAf;TM[N7 <br />� 3200 Cedar Streel <br />Everett. WA 9B2C11 <br />Phonr�259-BfitC. <br />� <br />O <br />� <br />N <br />O <br />a <br />l,OMNO' LCf�GL1.1UJ1 OI GONDITIONS <br />P,.�� und�ntiiy�;�'d ua�ne�-aPPLc�i�l li^rCbY �9reo510 h01d end 50Ve henn- <br />��ss iho G�Y ol Evc�clt hom any and all clnims lor damages, costs <br />e.pr.nses, oi cnuses ol action �hat may erise bocause ol inslallalion <br />and mnintenance ot Ihe impiovement or othar righ4ol•way use hereto <br />AppliEd Ior nnd f�r�her agrees �o remove samo upon notice Irom Ihe <br />Ciry antl ta replace pub4c pioperty damaged Ihereby. <br />/ <br />� / c,, Il� l 5"�E �/ <br />Dato <br />Siyn- rEb� Applicant <br />WOY7H AUTHORIZED DY THIS PERMIT MUST BE STARTED WITHIN <br />180 �AVS OF DAT[ PERMIT IS ISSUED AND TH[REAFTER IS TO <br />OC DII IGFNTL� �'URSU[0 TO COMPLETION THIS P[PMIT MAV �[ <br />,�alr:l.l.l I I� R'� n❑� ;-IiY tiPtlV n�dY ;i�ll'��; GE O�NOf7K ON THIS <br />i in,.11 t�J �,ll V: ���, I��',�', I,UHAIn)N <br />