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�"A APPLICATION FOR PUBLIC WORKS PERMIT � <br />� Type or prinl clearly wilh ink <br />i PRESS HARD • YOU ARE MAKING COPIES pERM1T NO. p� ��n _ <br />PUBLIC WORKS i <br />EVERETT, WASHINGTON � � BLDG. DEPT. NO. <br />❑ OWNER �AGENT DATE �L__1__L.�� <br />( <br />APPUCANT/FIRM REPRESENTED _ �.,111'�._-/,�u_J�t�� - _ <br />ADDRESS - =- �.1 S L-,. I b�� _ciTv r,,� �.� -ff_TELEPHONE _'_S� •/ i 9Y <br />HEREBY APPLIES FOR PERMISSION TO _ 1�r.�, .. i�_r,1a c_ �. �,,r w � _ <br />ATTHE FOL�OWING LOCATION _''�,)` --�� Cy� � L��. <br />o Attach five (5) copies of preliminary plans for proposed work. Draw to scale and shc�,v the following as applicable: <br />` Property lines and street identity. * Topographic changes requiring cuts and (ills <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 ot abutting right of way. t North arrow <br />; j I. , _ - - <br />-- —'Y.�-- S�gnalure ol APPlican�' � <br />�— _ <br />'-��/I <br />h% <br />CONDITIONS; <br />PERMIT IS VA <br />EXPIRATION <br />� PUBLIC WOF <br />_�, <br />, , �; � <br />I J \ `\ � � i <br />\ ' <br />�'� ` � <br />�� , <br />2 <br />. . �7t*i�ftt0. .� i <br />l�t :� 5 t 1 � <br />< <br />� <br />�.. . <br />� <br />� <br />1; � y�� � <br />�� <br />IT <br />---,� N <br />lhe imdci5�yned owne� hPreby ngrees �o �oltl and seve hermlass <br />ihc City ol EvCrn�� imm any ano an L12iTE IOf 431112QQ9, C06I0, <br />erpenses. or wuses ol action ihat may arise beceuse ol in9�Bllellon <br />-� and maintenenCe ol ihe improvemenl or oiher �iphFO��wNy �60 <br />herelo epv��ed lor and lurther agrees lo removo same upon notice <br />Irom Ihe City nntl to replace public proDerty tlamaged thereby. <br />ACKNOWI.EDGEMENT OF CONDITIONS <br />SIGNATIiREOFAPPLICANT DATE <br />FOR 1 YEAR <br />POST ON <br />JOBSITE <br />CALL FOR INSPECTION <br />259-8811 <br />24 i�RS. BEFORE CONSTRUCTION <br />i <br />� <br />