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Date PuDI¢Wo�ka Permit• <br /> �� AFplicationFor B�ap.Dec-�90/25340 <br /> PUBLIC WORKS PERMIT PubTo°F«"° s <br /> �ess AoO�Fee PaiE s <br /> Balanre Dee S_ <br /> Print or Type Oniy <br /> Group Health 521 Wall at. Seattle 98121 448-2420 __ <br /> Owner Maii�ng Address City Zip Phone <br /> Owner <br /> Applicent Mailing Address City Zip Phone <br /> Desciibe Proposed Work '�n��mp�oc��t . <br /> W <br /> ProlectAddress(ifknown) 1100 PacifiC Ave. _ � <br /> Attach lour(4)copies of Plans tor proposed work-Draw to scale and note the following as applicable: � <br /> � Property Lines • Centerline ot street � <br /> � Outline and dimensions of all existing antl • Indicate North <br /> proposed slructures on the lot • Show any proposed grading changes <br /> • Ezisting end proposed utilities � Show meas•�rements M <br /> W <br /> DO NOT WRITE BELOW?HIS LINE O <br /> PERMIT CONDITIONS <br /> 1.All calls for inspection shell be meae 24 hrs.in advance•phone 259•A810. � <br /> 2.All work ahall be peAoimed in accordance with this permit and current City ol Everatt Design and Construct�on <br /> Stenderds end Specificetions. <br /> 3.Call Location Underground Service 4B hrs.before you dig.TOLL FREE NUMBER 1-800-424•5555. � <br /> PU/� G/�,��.�..� �.-� ��,:`.;`�.�CP�'- 0 <br /> �_�o .- �o H- <br /> N <br /> O <br /> a <br /> ACKNOWLEDGEMENT OF CONDITIONS <br /> The undersigned owner/appticant hereby agrees to hold and save harm- <br /> � less the City ot Everett from any and all claims for damages, costs, <br /> ezpenses, or causes of action that may arise because uf installation <br /> and main!enance of the improvement or other right-of�way use hereto <br /> applied lor and further agrees to remove same upon notice Irom the <br /> .Opproved for Construction Date City and to replace public property damaged thereby. <br /> FINAL INSPECTION �a�e Date <br /> Approved as Constructed Signature of ApplicaM <br /> WORK AUTHORIZED BY THIS PERMIT MUST BE STARTF.D WITHIN <br /> everett PUBLICWOHKSDEPARTMENT 180 GAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> � 3200 Ceaer Street BE D:LIGENTLY PURSUED TO COMPLE710N. THIS PERMIT MAY BE <br /> Everett,WA 98201 CANCF.LLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br /> Phone:259�BP70 pROJECT OVER 90 DAYS DURATION. <br />