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yi � � <br /> Date G� _ ���nia wo,w,r�rmn. <br /> o��� o�o, . ��-a��: <br /> qpplicatlon For y. <br /> PUBLIC WORKS I�RMIT �°°°°W°"=°°° : - -_ <br /> �[ IaIN fce <br /> O Lcis Rnpl Fee PnN s — <br /> O r o0 <br /> � °. � v�i '� � o,i,���n�� S 3.� ,_� _ <br /> Print or Type Only ?s , <br /> ; c o � � � �+�z-3z2- 5io-le'D-/ti8.i/ <br /> �,�;n ���C11SJ ��'� ���-�'YP;� G'8'a0 I �7��'I`7Lc�fo�' <br /> Owner Maihn9 Atldres$p • r: x �o�tY.. ZiP �/� Phon/e —/�p <br /> � C U hl = l-/['hiT fl�J% l'•J �� <br /> �� O � G�] U) O > � <br /> � �` O J J O ic S <br /> �'L CL� lL ()l YF L�] C1 <br /> Applicant MailingAddressy City LP Phone <br /> Describe Proposed Work � `� I�I ' �� ' �` ' `�"" `�' ' ` �� <br /> ��n/J c� W <br /> Project Address(it knowN L�`�^-"� O' `" ��`��' � <br /> AttaCh four(4)COpies ot plans for proposed work- Draw�o scale antl note the tollowing as applicahle: � <br /> � Property Lines • Centerline of street � <br /> • Outline and dimensions of all eaisting and • Indicale North <br /> prOposetl structures on the Io1 • Show any proposed grading changes <br /> • Exisling and proposed utiiities • Show measuremenis � <br /> DO NOT WRITE BELOW THIS LINE O <br /> PERMIT CONDITIONS <br /> 1.All cells tor Inspection shall be made 24 hrs.in advance•phone 259•881 O. � <br /> 2.All work shell be performed in accordance with this permit and current City of Everett Design and Construction <br /> Standertls and Specifications. <br /> 3.Call Location Unde•qround Service 48 hrs.before you dig.TOLL FREE NUMBER 1-800•424-5555. � <br /> 7, J-GCC- �C7c"Z�✓ �LJ �, C/n2G'. �,2 �llvruli 4�,�Joz.'-�-c�' O <br /> �2 �r_���y7 ��y �d 3'�-� �ri� ��-,�.,�j', <br /> �'�x� � H <br /> ��� ��.���� N <br /> S -�`.�c�3 ��-7`3.z� �'v �� P�c�� �z.z. �t'1<`� S ����� O <br /> � a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/applicant hereby agrees lo hold and save harm� <br /> less Ihe City of Everett Irom any and all claims for damages. costs, <br /> expenses. or causes ol action that may arise because of installati�n <br /> ' , /� f�� // �� �� and maintenance of the impwvement or other right-ol-way use hereto <br /> ����'�f9� applied for and lurther agrees lo remove same upon notice from the <br /> Approved for Consir c � n Date City and to Rplace public properry damaged thereby. <br /> / <br /> vtG� a'i'�U I� <br /> FINAL INSPECTION Date � <br /> Approved as Constructed Signature of App ic t Dat <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br /> everett PUBLICWORKSDEPARTMENT 780 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200CedarStreet BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br /> Everett,WA99201 CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259•8810 PROJECT OVER 90 DAVS DURA710N. <br />