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eV" APPLICATION FOR PUBLIC WORKS PERMIT <br />Type or print clearly with ink, <br />PRESS HARD - YOU ARE MAKING COPIES <br />PERMIT NO. <br />PUBLIC WORKS `� S <br />\E�VERETT, WASHINGTON <br />03OWN ER ❑ AGENT DATE I- 3LDG. DEPT. NO. <br />APPLICANT/FIRM�yREEPRESENTED /uL <br />l A I�AU1//�--C <br />ADDRESS �f ffI Cs)�,Q CITY r,J LA TELEPHONE <br />HEREBY APPLIES FOR PERMISSIOl'- TO ZZ f-Htl!/ - 7C7 CO3.OVAAe-, fy VJ <br />P, 46 / GA2tdUe [ JL-eT 1bLt]!r� <br />AT THE FOLLOWING LOCATION _ ._S� ►'Lr <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 />• Outline and dimensions of existing and other than normal foundation. <br />proposed structures. On -site drainage systems when required. <br />• Existing and proposed utilities. ' Erosion control methods when required. <br />• Centerline of abutting right of way. North arrow <br />PUBLIC WORKS PERMIT <br />CONDITIONS <br />APPROVED FOR CONSTRUCTION DATE <br />APPROVED AS CONSTRUCTED DATE <br />PERMIT IS VALID 1'311 1 YEAR <br />EXPIRATION -- - <br />letil vie <br />The undersigned owner hereby agrees to hold and save harmless <br />the City of Everett Irom any and all claims for damages, costs, <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the Improvement or other right-of-way use <br />hereto applied for and further agrees to remove same upon notice <br />from the City and to replace public property damaged thereby. <br />ACKNOWLEDGEMENT OF CONDITIONS <br />SIGNATURE OF APPLICANT DATE <br />POST ON CALL FOR INSPECTION <br />259.8811 <br />JOBSITE 24 HRS. BEFORE CONSTRUCTION <br />