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Data -5 " � '°/ <br />4pplicahon For <br />PUBLIC V1IOF�KS PERMIT <br />Print or Type Only <br />��,5 � <br />Owner <br />, <br />G, i ' � .1,[ '� � �7_ <br />. ;; . � r,-.t, : i ,�r/��� � r <br />inB �ddress C�ty <br />Sv i�z- <br />��„�,����v:,k,��,•,�y��33 3 <br />em0 ocp� • � �--- —� - <br />Pub�¢Wo•Infrn t ���.Q�_._. <br />TotN Fec <br />�� <br />LP�e Appl fer PaiO `S �--�—�' <br />6q�nnre U�ir `S �� � � _ <br />� <br />('r ' ��N '%�Sr'��,/ 3;5� <br />i_ .;'r '���_—_ . <br />Z,n rnone <br />��'CU �c-7c; Phone <br />— Ci�Y Zip <br />Applicent Meiling Address <br />N`i�u o�-` lGVOC la��r�-�c� Ai?�utz���y <br />Describe Proposed Vrbrk �� _ _ <br />Project Addross (II known) y �) � <br />5 <br />- ��� - <br />,.n� • �'�' <-��'�r`- <br />q������ f�„� (4! copi95 0l P�an9 lof proposed work - Draw lo sc�le and noie � C�^�1erline oi stPeel a�l,'. <br />' Propo«y ��nes • Indicate North <br />• Outlme nnd tlim�nslons ol nil exrst�nn :�nd � ghow any p�oposed yraAiny chani�et <br />piopused structures on the lol � ghow measurem�!nts <br />• Lx�sting aM Pwposed utlli�ies <br />F'ERMIT CONDiTIONS <br />1. All calls loi inspechon sr.ail he made 24 hrs in advance - phone 259-881 5 <br />2 All work Shell be perlom�ed in accordance wlih Ihis permi� �nd aurenl Gity o� E �erc'il U��s-i9n ond Gonslruction <br />Standards end Spacilications. <br />3. i,all l.oca�ion U��der9raund Srivir.e 4Ei his h��1on' Y��� ���Sl TO_L FREE NUMBER 1•800•424•555 . <br />. __-___-._._. .... . _.._ _. <br />__.___ __-.-_ _ . <br />�� _ %'�%��.� <br />ovr,d <br />w <br />FItJAL INSPE�T�ON ( \ <br />Appwved as Cons�-ucted ��� <br />�,��,�i,��� PU�LIC VJORKS DEPARiME1J1 <br />� 3200 Cedar Sireet <br />Cverett. WA 98201 <br />PM1ono�.'S9�ti815 <br />W <br />H <br />�w <br />_ / <br />H <br />N <br />O <br />� <br />,1('t,Nl"1Wl{�l'GF�-�LM (>f" CONDITIONS <br />i h,� undeisigned ovmeunpPbcanl h��ruby c�9roes t0 ho�d ontl snvc ha�m� <br />�� �-� -- - � i,.,s tl�e Gly ot [verelt trom any and all claims lor damnpes cosls, <br />rxpenses, or causes ol aclion that may anse because ol inslallntlon <br />S z 1_} anA maintenanr,e ol Ihe mprovr,menl or olhcr righl-obway use heretn <br />AppiieA lur and lur�her agreos �o remov� same upon notir,e lrom ihe <br />Date C�IY a��d-10.re�lace puUIN�. proPertY dama4ied IherebY. <br />�(] _z� � / f�,' �_ � ,J , � <br />C1 __..) /'� l �� ���/ � � `Dat� <br />Jale <br />� ' Si9na(we ol APPIiGa <br />\VOhK AUTHORIZED BV THIS PERMR MUST BE STARTED WITHIN <br />iN0 DAYS OF DATE PERMIT IS ISSUED AND THI=REAfTER IS TO <br />f3[ �II IC;CNTLV PURSU[D TO COMPLETION THIF PERMIT MAY B[ <br />(.i.Il� i�. I 1 P R1 T I I!_ : ITV UPO�J AHV STOP1'�1GF_ OF NJ07K ON TI11� <br />I'iu � J�7�.1 I+ .. I.a�", f�URr,iu��l <br />� <br />C. <br />