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i <br />pafo ,3/ � <br />AppliCatinn For <br />PUSLIC WORlC� PERI�IIIT <br />Print or Type Only <br />Ownar <br />Applicant <br />8� -3.3 <br />Puof�cWorksParmlt> — <br />Bltlg. Dnpt • <br />Publlc Wo�k! Fve S <br />TolalFoa — <br />Less AO�� Foe Paid S_ ��—� <br />�alanca Duo 5 <br />�+ 5�oa Jtf�1 57 5� <br />S�6 Y' �- ��—/ �/ �n o 1e'j'' r.,v ),j-r c- � �. h WU b LI . G'-� �/ , G" % <br />Mailing Addiess C�ly p'] 7 ��— ���n� <br />5i 1 �.�n �,c/t : v y�� .�, 3.� 7-,� , <br />t i F. .J '�. r l� <br />Mailing Address City Zip Phone <br />i <br />i <br />�,,1,_ ,_,,.,�".c- :�v-�v� �� y 16� h ar <br />Descrine Proposed Work <br />� Project Address (if k^own) �_., '� �T---/- " - <br />i <br />Attach four (4) copi=s of plans for proposed work - Drew <br />• Properry Lines <br />• Outline and dirt:ensions of all existing and <br />, proposed strucWres on the lot <br />• Existing end proposed utilities <br />�! <br />f <br />� <br />and note the f[fllc,wing as applicable: <br />� • Centedine of street <br />• Indicate Norih <br />i Show any proposed grading changes <br />• Show measurements <br />PERMIT COIJDITIONS <br />1. All calls tor inspection shall be made 24 hrs. in advance - phore 259-881 5. <br />2. All work shalt be performed in accordance with this Fermit and current City of Everett Desi9n and Construction <br />Standards and Specifications. <br />3. Call Location Undergrnund ��en�ice 48 hrs. before you dig. TOLL FREE NUMBER 1-800•424-5555. <br />/� ��S/ S/�G/.J �T .l��i4EL•JQ� � � L L!i %L!f'/l�l//JC���-- <br />� T.e�/J.�'f.'c ��'iir/a6'J <br />�✓� ��r�_� -?i'���6 <br />tor C�nSiruction Date <br />///�l/l��JP"l%/�`'t'`� Z-zd ��' <br />�� ,,,-R � T � Date <br />Approved as Constructetl' v <br />evere[t PUBLIC �70RKS DEPARTMENT <br />� 3200 Cedar C:re=t <br />- Everet6 WFl 98201 <br />Phone: 259-8815 <br />, <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/applicant herehy agrees to h;Nd and save harm- <br />less the City of Everelt from any and all r,luims tor dam�ges, costs. <br />expenses, or causes ot act�on ihat may anse because oF installation <br />and maintenance of the improvement or other right-of-way use hereto <br />applied for and further agrees to rernove same upon notice irom the <br />City and to replace Public property damaged thereby. <br />SignaW e of Applicant Date <br />WORK AUTHORIZED BY THIS PER IT MUST 8E STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSU�D AND THEFf_AFTER IS TO <br />BE DILIGENTLY PURSUED TO COM?LETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />Z <br />0 <br />-� <br />.. <br />n <br />r: <br />� � <br />.. -i <br />�n x <br />r• � <br />=v <br />�, o <br />c"� <br />om <br />_ —�f <br />m <br />.. <br />,o z <br />rn- _ <br />.. <br />�--� N <br />� <br />-n <br />o� <br />T 3 <br />--i m <br />rn� <br />0 <br />� <br />� m <br />C N <br />3 N <br />i� <br />(� <br />� m <br />A <br />� <br />2 <br />a <br />z <br />--I <br />._. <br />N <br />z <br />0 <br />� <br />.� <br />n <br />m <br />