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APPLICATION FOR PUBLIC WORKS PERMIT <br />PERMIT NO. __03 5 <br />Type or print clearly with ink <br />PRESS HARD • YOU ARE MAKING COPIES <br />PUBLIC WORKS <br />T. WASHIN BLDG. DEPT. NO.— _ <br />D OWNER NuENTENT DATE / <br />APPLICANT/FIRMREPR�ESENTED __-_�.-------- -- - <br />ADDRESS _—J-1 d.. � CITY J_'_)�'TELEPHONE 1L 5 <br />HEREBY APPLIES FOR PERMISSION TO <br />AT THE FOLLOWING LOCATION <br />Attach five (5) copies of preliminary plans for N: opposed woi k. Draw to scale and show the following as applicable: <br />• Property lines and street identity. • Topographic changes requiring cuts and fills <br />• Outline and dimension s of existing and other than normal foundation. <br />proposed structures. g On -site drainage systems when required. <br />• Existing and proposed utilities. • Erosion controjaieihods when required. <br />• Centerline of abutting right of way. • North arrow <br />Signature of Applicant <br />coNofTloNs: PUBLIC WORKS PERMIT <br />The undersigned owner hereby agrees to hold and save harmless <br />the City of Everett from any and all claims for damages, costs, <br />expenses. or causes of action that may arise because of Installetlon <br />and maintenance of the Improvement or other right-ol-way use <br />__ 11-1 r.....w r. �.re...nm.. I.,r.mnvw game unon notice <br />7 <br />