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i <br /> r , il <br /> � <br /> �I <br /> , -- <br /> � <br /> �everer APPLICATION FOR PUBLIC WORKS PERMIT <br /> TYPe o�P�int clearlY with ink <br /> PRESS HARD-YOU ARE MAK.ING COFIES ��,j, /� <br /> �— <br /> PUBLIC WORKS PERMIT NU. .� <br /> � EVERETT,WASHINGTON BLDG. DEPT. �'O. <br /> ❑ OWNER (3�AGENT DATE ,7�_�� <br /> APPLICAWT/FIRM REPRESENTED .L^hri � f��n e_���C��s�e.-.,� .^4'_� I�1 <' c' __ <br /> ADDRESS �/ �ii c�c;���r�U� Q� uY (`,�Ty 'JP/Y {- TELEPHONE �s`�` 3`16.ri' <br /> HEREBY APPLIES FOR PERMISSION TO �� �� S� �A .t9a � I' <br /> ��J I� ' <br /> A.TTHE FOLLOWING LGCAiION �'f'3( Ga) b�_ /���,�u � �N�w< <c1'r�Nr o-� n c r-r���� <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. • Topographic changes requiring cuts and fills <br /> ' Ouiline and dimensions of existinc� and other than normal foundation. <br /> proposed structures. * On•site drainage systems when required. <br />' " L"xisting and preposed utilities. • Erosion control methods when required. <br /> ' Centerline o: abutting right of way. * North arrow <br /> . <br /> Gd,G�(�•c3ti:i ��c (���st,�, <br /> _�,.� Sfgnature oi Appliwnl <br /> PJBL�IC WOf�KS PERMIT <br /> CONDII'IONS: <br /> -� - -r�- - ' ' �i_ � h� � <br /> � , 1 <br /> - _1_ �1 � i `T <br /> -'. <br /> � i � �, � �. ic), -1 •-,� � � � : <br /> ' � --i--� -�-� � � . - - - �-r t�--�- � <br /> -+- - _�� - - -�- - - ��: �;� -� <br /> + ; , , - i� ' <br /> i ; � � <br /> -� �r • .�.. i _ � ' i I -1 � � <br /> _� <br /> 1 I ♦ <br /> � �� I i <br /> � L y � I <br /> � � I <br /> r�l� • I -} I --'i�� i � �� . i � i �-� i <br /> -it ' 't �i--_ _ ' ��� i�--�_ - -� , . -Y-- , 1 <br /> v � _ � _ ^��-- , t _' � --��f- -' , I � . <br /> i , <br /> } �.._._ .--_ � _ .�_. .,_.__�_ ~ <br /> i � <br /> �'i�' <br /> � <br /> ' i _ �i--1-t __�--'-_� r � ..�.i -�. . :- . } - . -�:--._ '.�_.-_`' <br /> � <br /> _ . _ _ _ _ _ _ _+ _. -� _ ..-. } :� �.. :.. -:- � � . <br /> i : � -. -- _ �. , . i i �, . . ." <br /> � -t�- � �� - 1 ' � The �mda•signed owner hereby egrees to hold and seue harmleas� <br /> � � I I�e Cily ol Everel� Ircm any ano an ciaims for tlama0os, costs, <br /> �1 . � Tj' . _ _ _ . - j <br /> .1 � I +-l-.- eapen9eE,of ceU5B5 Cf HC�IOn�hai may eflse bdWu6o o�Inllelle110n <br /> -T 1 -� en0 maintxnenr.e ol Ine improvemonl or olher righPobway uee <br /> � I i �rt"�' � i� hereto apPi�ed for and lurlher egrees to remove snme upon notice <br /> � � 1 - lrom �Ao Cily and to reDlace public property damaped there6y. <br /> �._ � �—����>c8 .�= .: <br /> � VED FOR CON �Cb�Q � E ACKNOWLEDGEMENT OF COND'TICNS <br /> `-'�� �/,��- �-�-dt/ � / � <br /> ��aer� �✓� / ['///..��C�z''t'YL Cv ' C7"�'._-�__� ,..ZS .�f�.J _ <br /> PPROVED AS CONSTRUCTED DATE �SiGNATUFE OF APPLICANT DATE <br /> �ERMIT IS VALID FaR i YEAR pOST ON CALL FOR INSPECTION <br /> �- JOBSITE 259-8811 <br /> EXPIRATION 24 HHS. BEFORECONSTRUCTION <br />�' <br /> � � <br />