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APPLICATION FOR PUBLIC WORKS PERMIT <br />rolType or print clearly with Ink <br />PRESS HARD • YOU ARE MAKING COPIES pERM1T NO. ,2 7 3 <br />tr' Tel IC WORKS <br />' Viz- ETT, WASHINGTON C BLDG. DEPT. NO. <br />LT OWNER ❑ AGENT DATE 7- <br />P.P°I (CANT/FIRM REPRESENTED <br /><J 7 l C►3 CITY �lC+�r1TTELEPHONE L y-�� <br />ADDFlESS _% � <br />HEREBY APPLIES FOR PERMIS;iION <br />/1 <br />AT THE FOLLOWING LOCATION <br />Attach five (5) copies of preliminary plans for proposed work Draw to scale and show the following as applicable: <br />• Property lines and street identity. <br />• Outline and dimensions of existing and <br />proposed structures. <br />• Existing and proposed utilities. <br />Centerline of abutting right of way. <br />Topographic changes requiring cuts and fills <br />other than normal foundation. <br />• On -site drainage systems when required. <br />• Erosion Control methods when required. <br />• North hrrow <br />The undersigned owner hereby agree, le hold and ,eve harmless <br />the City of Everett iron any and all claims for damages. costs, <br />es penses, or causes of action that may el Ise because of Installation <br />end maintenance of the improvement or other right of -way use <br />hereto applied for and further agrees to remve same upon nolloe <br />iron, the City and replace public popedy damaged thereby. <br />NSTRUCTI N DATE ACKN, LEDGEMENT OF CO IT10143 <br />1PPROV�O <br />k O A C S CTED IGNATU RE OF APPLICANT DATE <br />PERMIT IS VALID FOR 1 YEAR CALL FOR INSPECTION <br />POST ON 259-8811 <br />JOBSITE 24 HRS. BEFORE CONSTRUCTION <br />EXPIRATION ____ <br />