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Date-3�:H�� : <br />AppLcaUon For <br />PUBLIC M/ORKS PERMIT <br />Print or Type Only <br />i���n�,�. w���: r.�m,i . 9 � � ' . <br />ein� o�n� • _91/267Q.2----- <br />v,mi�c wo�1n r�, <br />Tnln�fnn S <br />1�.4\ FI�III lfl. {'Tiit A <br />,,,.,� ,..,,,. <br />Dujardin Dev. PO Box 5308 I;Vcrett 9�20G _ 33A-5_O18 <br />OWner Mlilin{)AJdn•�,s C��Y Lip Phonc <br />Owner <br />Applicant <br />ilmq Addre55 <br />DeScriho Proposed V+ork __��t�i��.qriw—Sincfla—family--tasid¢nCe <br />Proicr.t Addre55�if known) 29-�Sth St <br />� <br />Attach Ic-rt I�I copies ol plans fo� P�oPoseU work � Draw to scale and note the iollowin{� as apphc�ble� <br />• Property Lines <br />• Oulfinr, anA dimensions ol all c.isUnq anA <br />propo5ed Sifuctufe5 on Ihe lol <br />• Exis�in9 and proposnd utilities <br />• Cen�crhne 01 str�el <br />• Indir,ate Noi�h <br />• Show any proPosed yiaNnp chanqes <br />• Show mr,asuremrnis <br />DU NOi WNITE �FLOW T�i15 UNE <br />Phone <br />PERMIT CONDITInNS <br />1. All calls lor inspection shall be made 24 :�:s. in ativance � phone 2b9•8Bi 0, <br />2. All work shall bo pertormed in accordance with IhiS permit and wrrenl City ol Everett Design and Construclion <br />S�anAards and Specilications. <br />3. Call Location Undergro��nd Servlce 4B hc:. betoro you dig. TOLI FREE NUMBER 1•800•424•5555. <br />9. IneY.al l rock coneY.rucY.ion entrAnr.o behind driveway a: per city <br />etandard 't20B to redur.o trackin� mud onto etreete ar� eroaion <br />control. ea dire�.�Y.e�d by Publ3c Worke Int�pector_ <br />5_ Koep cit:y ntre�to cl�en aY. n] 1 timee. <br />8_ Curh, Rutt�r nnd•r�idevrr�lk in the plr�t are nea and undamng�d, <br />any damaRe thernto nhnll be repl.�ced at the diecret:ion of the <br />� <br />�_ <br />]0. <br />Public Workn Innpoctor. <br />Any rhange in tt�o driveway cut muet be approved hy the <br />Public Worke Inepector_ <br />Tightlino all roof, yard and drivevi��y drt�in� from houeea to ntorm <br />drain ntubn at: b�ch. of aide wulk with rubber genket P_V.C. pipe. <br />Ad,juet wator boxe� Y.o grnde at end of conetruction. <br />Drivawaye ohal] be comPlntaly r.urad before drivin� on them_ <br />��.M�� �-a-5� <br />ApprovedlorConslrucuob� Date <br />� �' <br />�; �_� �� �- % j�-%% <br />-.- <br />fIN�NSPECTION Date <br />Appioved as Canstrur.teA <br />�wri��11 PUBLIG WORKS DEPARTMENT <br />� 3200 C�dar Stirel <br />[vernlL WA �..�701 <br />Phonr� ?S9�Hn 0 <br />ACKNOWLEDG[MENT Of CONDITIONS <br />W <br />� <br />� <br />� <br />O <br />Thc undersiqn�tl owne�/aPPlicant he�rbY �9�ces to I�old,ui�l sdve r�.�i:i� <br />less Ihr. C��y ol Evcrell Iroin any anA all cla�ms lor Aamaqes. c�.isls <br />enpenses. or r,auses ol artion Ihat may anse becausr, ol msl�llation <br />and mamtenanr.e ol tne miprovemenl oi othei nght-ol�way use herelo <br />appluud Ini and lurthe� ag�ees to remove s�me upon nolicn 6om Ihe <br />GIY i��d m n•place public property dama9eA �herebY. <br />� <br />� <br />Si9na�we ol A ican� Dalc <br />WOIiK AUTNOR17_ED OY iHIS PER IT MUST BE 5(ARi[D WI7HIN <br />1B0 DAYE OF DATE P[RMIT IS ISSUED AND THEPEAFTER IS iU <br />OE DILIGENTLY PURSUED TO CObIPLET101J. THIS PERMIT MAY f3E <br />f,ANCELLED BY THE GTV UPON ANY S70PPAGF OF WOfiK ON Tlliti <br />PROJ[CT OVER �0 DAVS DUfiATION. <br />