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- ` <br /> e°e`e" ' APR'LiCATION FOR PUBLIC Wf)RKS PERMIT <br /> � TYPe or print clearly wilh ink p <br /> PRESS HARD•YOU ARE MAKING COPIES pERMIT NO. � � 5 O <br /> PUBLIC WORKS <br /> EVERETT,W.ASHINGTOI� _ ^ BLDG. DEPT. NO. <br /> ❑ OWNER ❑ AGENT DATE ' � ' �— <br /> i , , a ;�'�!C,. . .` � �. <br /> APPLICANT/FIRM REPRESENTED '� �'�'f�'' = -- �� '' <br /> ; ,<) i;� � y� _ r ; ., � ,. iCITY TELEPHONE .�:J 3. C;.�G � <br /> ADDRESS - " , <br /> HEREBY AFPLIES FOR PERMISSION TO '- t' ' ` ` <br /> ; , . <br /> � /�/ v� <br /> r . — <br /> AT THE FOLLOWING LOCATION � ��` - � � �f J ' ` � ' ' � � � � <br /> Attach five(5)copies of preliminary plans for proposed worlc Draw to scale and show the following as applicable: <br /> * Property lines and street identity. ` Topogr�,phic changes requiring cuts and fills <br /> * Outline and dimensions of existing and othei 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 /> i,_,�f.,�..)::�J l.� ; ..i . ✓ ,� _ <br /> Signatum ol Applic nt <br /> PUBLIC WORKS PERMIT <br /> CONDYTIONS: <br /> , . . , _ . . j ' . .. . <br /> . . . . ; . . . . , <br /> . . . . . � . . . . . . <br /> , <br /> � ---__ _ ._- __. _.,_._...--- _ . <br /> _ - . . t" . <br /> � . <br /> . . i .. <br /> . . __.�.---•.:_.,_. <br /> � . , <br /> : ' � . . � . <br /> ; . . '~ , : . .,�_ i . . , <br /> , <br /> , . . . . . � :. , � . , <br /> , <br /> ._� ..... _____ ,--- . . _ . . . <br /> , . _ - � - -; . . . . . . : . _ <br /> � . . . � . . . , • . <br /> ; . . . . . ; , <br /> � � --�--r^---'-T"� " - � � � � � � � The undersignetl owner hereby agrees lo hold and save harmless <br /> � � • ; • ` ' ' � � � the Ciry ol Everetl Irom eny antl all cicims for demaBes, cos�s, <br /> � � ' ' � ' i ' � expenses.or causes of action that may adse because of installa�inn <br /> � - " ' ' ' � ' � � . and maintenanco of Ihe Improvemenl or other righ4ol-way use <br /> . . ._. . .. . : . . , . <br /> � . . . hereto applied for nnd luriher agrees to remove same upon notice . <br /> � , . . � Irom �he Ciry and to replace public property dameged ihoreby. <br /> ��� � <br /> �'"__`G /� .�,�� �•-�-�,� � . <br /> �,APPR VED F NSTRUCTION DATE ACKNOWLEDGEMENT OF CONDITIOItlS <br /> 3-zz�Z- ';_� =� _, i �:! � �� ,�{-,, -:: _��, � � <br /> - P ED AS CONSTRUCTED DATE ' SIGNATURE OF APPUCANT � DATE <br /> PERMIT IS VALID FOR 1 YEAR CALL FC',�i INSPECTION <br /> POST ON 259-8811 <br /> EXPIRATION � � Z � � � JOBS�TE 24HRS. fdEFORECONSTNUCTION <br /> . <br />