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everett APPLICA'► _JN FOR PUBLIC WOF._.S PERMIT <br />� TYPe or Print cleady with ink � <br />PRESS HARD - YOU ARE MAKING COPIES pERMIT NO. �'" �' '� <br />PUBLIC WORKS � <br />EVERETf, WASHI,N/GTON ; BLDG. DEPT. NO.-- <br />❑ OWNER d?\GENT DATE _!�� �L',��' �___ <br />APPLICANT/FIRM REPRESENTED <br />ADDRESS —_ <br />HEREBY APPLIES FOR PERMISSION TO <br />---�— ---=+ �=--_ . --- ----- <br />_CITY � � ° - TELEPHONE <br />i H _ _ <br />ATTHE FOLLOWING LOCATION - -- ------- <br />��;.'�T- ...' :, . . . � . .. � ; , . . . <br />Attach five (5) copies of preliminary plans for proposed worl<. Draw Eo�scale and show the following as applicable: <br />* Property lines and street identity. <br />* Outline and dimensioi�s of existing and <br />proposed structures. <br />� Existing and proposed utilities. <br />* Ce.�terline of abutting right of way. <br />CONDITIONS: <br />� <br />. . t;'< , <br />* Topographic changes requiring cuts and filis <br />other than normal foundation. <br />* On-site drainage systems when required. <br />* Erosion control methods when required. <br />� North arrow , . :.�,- 1 :.�,� ,.; <br />�� � Si9naturo ol Applicanl _ i ; <br />PUBL.IC WORKS PERMI <br />�< . , � -� <br />_ �/ % <br />: /,/ <br />�� f' ;1,-'�• '. —•:—� . <br />APPROVE�FOFCOtJSTRUCTION DATE <br />APPROVEU AS CONSIRUCTED � DATE <br />PERMIT iS VALID FOR 1-Y.FJA13� <br />,. ,,,_ <br />EXPIRATION � ��'�`� <br />, �•fr� � ,� <br />,;� : -. <br />Thc unUomgned av+ner hereUy a9rees to holC &iid save harmless <br />ihe City ol Eceie�� nom any anU .II claims lor damaqes, costs, <br />uxpenses, or causes of actipn Ihat may arise because o( installation <br />and maintenance ol the improvemen� or other righ4ol�way use <br />herelo app'�ed lor and lur;her agrees lo remove same upon nolic= <br />Irom the City and to replace pubiic property damagetl thereby. <br />ACKNOWLEDGEMENT OF CONDITIONS <br />SIGNATUREOFAPPLICANT DATE � <br />CAIL FOR INSPE�TI01�! <br />POST UN 259-8811 <br />JOBSITE 24 HRS. SEFdR� CG�IsTRUC710N <br />