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Date-�L--9�`' <br />Apnlication For <br />PUBLIC WORKS PERMIT <br />Print ar Type Only <br />r„ir�, wana r.���n � / ��� <br />o % <br />eitlp oeo� • --- -- <br />PuM�cWorMslee s "T4,�70 <br />totei Gee <br />lxff ApW r�e v�m S —� <br />�a�.vnrn Du� S•'�A• U O —_—_ <br />G 7.�38' <br />'/� �, , ,� .;� �7,,_; ��_ . �Itik< <rg; E=v_rz'�:�7 y�'�/ 3s.z� yy;� <br />�/LLlS �ICn�E51 t, � _ �;�Y up Phnn� <br />Owner Ma�n� g Add�r..� <br />(9LG,(,k''�' <br />�nplicant <br />A�7dress <br />CiIY Zip <br />/ti,s.r,�t� o-�s' �cu�� �r.,,.rac=r� �,cr�����ti -- <br />•�•.�.��be Proposed Work <br />Projecl Address lif known) _� � � ' " '�--- <br />Attach four (4) copies ol plaus lor propoeed work - Dmw tu scale anA note iho tollowing ns aPPlica6le. <br />• properly Lince <br />• Oullino end dimansinns ol aill eKrsting anA <br />pwposad struclwes on thc �ot <br />• Existing end proposeA utililies <br />• Centerline uf streel <br />• Indicate North <br />• Show 3ny proposetl 9radiny dianycs <br />• Show measurements <br />�.. <br />PEfiMIT CONDITIONS <br />1. All r,ells �or insprction shall he mnAe 7d h�s in ad�unce - phone 259•881 5. <br />� All work shell be Perlormed In acco�dan, e w'itn this peimil nnA cw�enl Cdy o1 [���=<<dt Dr s,an (�nd Co �struc�ion <br />Standards nnd Specilications. <br />3 Ca�l Localion Undergrnund Se���i<:� �1l3 hrs h�'�u�c Y���� dici TOLL FREE NUMBER 1•U00•424•5515. <br />____ _ . �.._ .__._ . .- <br />�� — —__—__ — . <br />- - a�� �� 6 -�' - <br />lµ�pieved lo� Cons cl�on D�Ir <br />_� --��s�-- <br />1 INAL INSPECl10IJ ��� <br />Approved ns Consiru��.trd <br />„��,�i,❑ PU6LIC WORKS DLPARiMENT <br />� J200 Gedar Street <br />[ v� relt. WA 9A?Ot <br />� �'h - u,. .�q�Afl 1 5 <br />— � <br />nc,r.rio�vi rocErauai or r,o•,�,n�oras <br />W <br />H <br />� <br />N <br />Z <br />O <br />i r,,. i, „i,.�.�.��.r�.��d ovma/aPPlicanl herebY ��9rce� to hold anA save Pa��»' <br />i�., •. in�� t:dv ut Everetl Irom any and all claims lo� damages, costs, <br />,,,p�,nsc;, oi raUses ol adion �het may eriSe beGBuSe o� �nStaliolion <br />;�nd mam�enance ol the improvement or oiher righbobwny use herctn <br />,ippiied lor end lurthe� agreea to remove seme upon nolice Irom tl�c <br />C�ty artd replar.e pu ic nroperty demaged therehy. <br />� lK � _ -- <br />� <br />�_ _,-�_t� <br />� o.,i�a <br />Si9ri ure o� APPIit t <br />WQaK AUIHORIZED BY THIS PEfiMIT MUST �E STARTED WITHRJ <br />180 DAYS OF DATE PFFM�T IS ISSUED AND THEREAFTEN IS T�� <br />EiE DILIGEIJTLV I U�`�UE� TO CO�dPI FTION TNIS PC_RMIi MAV BC <br />CANCELIED F+ I��I , �It �� '.'�'� -.1(�I°i'nr;l r7f AVqf7V<!]N'rU`�+ <br />1'RO-I�_C.� flA'I H I�: �'. I 11. I, �!1 <br />� <br />r <br />c�n ;- <br />U� <br /><; � <br />r! _ <br />� <br />� <br />� <br />�, ' <br />-� : <br />n <br />�� <br />r : <br />� . <br />�� <br />,� ; <br />Q <br />� <br />r:� <br />