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<br /> °"`rcn APPLiCATION FOR PUBLIC WORKS PERMIT
<br /> � T)'Pe or print clearly with ink
<br /> PRESS HARO•YOU ARE MAKING COPIES pERM1T NO. �� � � ��-'
<br /> PUBLIC WORKS
<br /> �VERETT,WASHINGTON BLDG. DEPT. NO. !
<br /> ❑ OWNER �AGENT DATE g �� s '�'
<br /> ) �-- J� �/
<br /> APPLICANT/FIRM REPRESENTED �?r1��r�C I� /✓!S f _L-�_ _
<br /> ADDRESS `3 �O � ��C,7 a W��� CITY !`''r��`J� TELEPHONE �S 'Z - �' � ��
<br /> HEREBY APPLIES FOR PERMISSION TO h'Q vc 4ir f du 7�/1rc� � r
<br /> 3 0 / �j,'"p�+�(,u J _ ��/, // !C ?`�e u e e� �u;�d/ir 9 f�a_S'P
<br /> ATTHEFOLLOWINGLOCATION _�� P�� "' r��'" ���y /
<br /> Attach five(5)copies of preliminary plans(or proposed work. Draw to scale and show the tollowing as applicable:
<br /> ' Property lines and street identity. ' Topographic changes requiring cuts and (ills
<br /> • Outline and dimensions of existing and other than normal (oundation.
<br /> proposed structures. ` On-site drainage systems when required.
<br /> • Existing and proposed utilities. • Erosion control methods when required.
<br /> ' Centerline ot abutting right ot way. " North arrow
<br /> Siqnature ol Applicant
<br /> coN�irioNs: PUBLIC WORKS PERMIT
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<br /> � �. ._ .. .,.I ; ..,_. .'. _ The undersigned owner hereby agrees to hold end sava harmleas
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<br /> . ` �_� i „� . . . . . - . Ihe City ol Everen trom eny ana au cla�ma lor damapen, coetn,
<br /> , , j ',_ . . - eapenses,or causes ol action ihat mey arise becauae ol In�lellallon
<br /> �. ,. �� � end maintenance ol ihe improvamen� or olher dphl-obwey uee
<br /> 1 hereto applied lor end lurther agrees b remove aeme upon nmlca
<br /> i , � ' /�� Irom ihe City an0 to replace Ou61ic procehY tlameQed Ihereby.
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<br /> (.1�- .��t. �� ��i r` �!J �._.
<br /> �q VE OR CONSTRUCTION TE / ACK OWLEDGEMENT OF CONDITIONS .
<br /> A ROVED AS CON T CTE �D���� I�ATUR�01=A/PPLICA T/�,,I �/f��TE �/,/' �
<br /> C PERMIT IS VALID FOR 1 xEAR CALL FOR INSPECTION
<br /> POST ON 259-8811
<br /> EXPIRATION �c/� �� ' JOBSITE 24HRS. BEFORECONSTRUCTION
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