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�:..:AI <br /> 1 <br /> � <br /> Date�/��! �/ PunFc Wods Prr=—il e / � <br /> Q..�/ <br /> mae oeo�.. ii�ii c.7 <br /> Ap�lication For � <br /> PUBLpC VVORKS PERMIT PubIrtVJOikaiee , <br /> ToiaiFee 5 I <br /> Less ADG�.Fce Pmd S I <br /> eaiaocn ouo S I <br /> ��"� Print or Type Only <br /> ��H �, % <br /> H I <br /> c�x=y �.,� ;���1-1. ��i_�.��� �'���1 �.a�=���ae�n u �����— � <br /> H 93 Owner MailingAddress ��Ciry L one � <br /> H ZH <br /> O x0 I <br /> '� y H �Npplicant Mai'ing Address City Zip Phon= . � <br /> I �i <br /> � x� �l''C��J�lD/� ��� �, � <br /> y d Describe Proposed N'ork , � <br /> � <br /> I ' <br /> � �g i <br /> �,� � � , <br /> zy� ' : <br /> z ��l)/ �! d�� � � <br /> � I—�y Projecl Address I:f known) ��' � <br /> y <br /> ~ Attach lour(4)copies of plans tor proposed work-Oravi to scale and note Ihe following as app6caUle: � <br /> g d�, � , <br /> C� C� • Properry Lines • Centerline ot streel <br /> 3 Cl1 • Outline and dimensions ol all existing and • Indicate North <br /> �t� i Show an ro g 9 <br /> Z y C/� proposed sVuctures on Ihe lot y p Posetl�radin chan es <br /> H O fA • Exislin9 and Proposed ulilities • Show measumments /iy� � <br /> W ' <br /> �O NUT WRITE BELOV. THIS LINE � <br /> PERMIT CONDITIONS � <br /> 1.All calls for inspection shall be made 24 hrs.in advance-phone 259•8810. � R <br /> : <br /> � �, 2,All work shall be pedormed in accordance wilh this permit and current City ol Everell Design and Construction � <br /> S�andards and S�eci'ications. <br /> 9.Call Location Underground Service 48 hrs.6efOre you dig.TOLL FREE NUMBER 1•800•424•5555. s� 1 <br /> I � G ' <br /> �.,.� �cau � ��/ok_�c.s r�r�iT /�O� — O i <br /> �� . <br /> �-..s l�.t.��.. t�'1 =-�c�� � <br /> � -7- 2-�{ -9 0 ♦�^ i <br /> ',�`i _--���- V+ ' I <br /> �� O ' i; <br /> ����� � � <br /> m .� <br /> � ACKNOWLEDGEMFNTOFCONDIT <br /> `' "� The undersigned owner/applicant hereby a9recs to hold and save harm- <br /> less the City ol Everett Irom any and all claims lor dama9es, costs. , <br /> eapenses, or causes ol action that may arise hecause ol ins�allation , <br /> and mainlenancr of ihe improvement or olher right-al�way use hereto . <br /> '��.. applied lor and lunhe� a9rees to remove same upon notice Irom lhe <br /> Approved for Construclion Date Cily and to replace putlic properq'damayed th�reby. I <br /> II <br /> FINAL INSPECTION Dale <br /> ApP�oved as Constructed Signature ol ApPGcant Date <br /> WORK AUTHORIZECI BY THIS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLICWORKSDEPARTMENT 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � �200 Cedar Siree� BE DILIGENTLY PURSUED TO COMPLETION.THIS PERMIT MAY 9E <br /> Everett,WA9C201 CANCELLEL BY THE CITY UPON ANY STOPPAGE OF WORK ON TIiIS <br /> Phane:259�8810 PROJECT OVER 90 D�YS DURATION. <br /> I <br />