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/ <br />everett APPLICATION FOR PUBLIC WORKS PERMIT <br />� TyPe or prinl clearly with Ink <br />PRESS HARD • YOU ARE MAKING COPIES <br />PERMIT NO. 3 <br />' PUBLIC WORKS <br />EVERETT, WASHINGTON DLDG. DEPT. NO. <br />❑ O�A'NER �'AGENT DATE °` � � � " 1 <br />L �- ( <br />APPLICANT/FIRM REPRESENTED _ � �� 0. �`�'�-�-�1��L.��� tu_-�._ ����. _ <br />� � <br />ADDRESS� � - `-> � 1� � Z-"� �, CITY �J `'�-'�� TELEPHONE � - -3���Z <br />� <br />HEREBY APPLIES FOR PERMISSION TO Irn s��..,.T' /��'J/OVCMPn�s �r���.�%.,i., 1 �i� <br />Fi•- S{f,F,�„ r/ <br />ATTHE FOLLOWING LOCA'iION 95 .� v �ut��4,i.��, Guo <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. <br />' Outline and dimensions of existing and <br />proposed structures. <br />� Existing and proposed utilities. <br />* Centerline of abutting right of way. <br />• Topographic changes requiring cuts and fills <br />other than normal toundation. <br />` On-site drainage systems when r�quired. <br />" Erosion control methods when rc:quired. <br />' No h arrow <br />_�,y�'�� �_ V�.– � <br />Signa�ure ot App cant <br />PUBi.iC WORKS PERMIT <br />CONDITIONS: <br />�' . . .. � � }�er : �la�s : a� Pr�v�� i a • a3 -81 <br />;{_: 1:. ;.. ; <br />�, " � .., _. <br />� _ �. _� .� ._.� - . <br />,� ,.. , ,, <br />; <br />, 1 ' i ' ; _ � . ._ _ � `.... . . . . <br />�- � i- <br />i . :. �... <br />t: � : � ;, : '. <br />-, _____� �'� _ __._._ 1 --. - <br />,,; <br />�;, {-� 1..:1 ' ; : <br />, ._ � . . <br />� , ( <br />:_: j;� � _� -: : <br />, <br />.; ..,. '_. <br />__-- ----+--_____�_ __y��_._..�.__. . <br />.._ ;...� . ,.. ... <br />� <br />. . . . . . �.. . . . . . ��....� . . . <br />. . . . . . . I . . . . . . . . . . . .. . <br />_ _ .. . . . . • . . . ... . . . . . . . . . . <br />. . . . . . . . . . . . . . . . . <br />. . . . . o <br />v�>����� <br />: ..: '...',.: :.. <br />Tho undcrsignod ownnr �oreby agrees lo hold and save harmless <br />Ihn Cily of Everc�l irom eny and ml clalms lor tlamaBes, cosis, <br />expanses, or causes ol action ihat may eriso because ol installelion <br />and mainlenanco oi Iha Improvemonl or ot�er ripht�ol�way uso <br />hereto appliad for and lurthor aB�ees lo �emove seme upon notice <br />Irom �ha Cl�y and lo replace public pmpetly damoged Ihereby. <br />DATE A�KNOWLEDGEMENT OF CONDITIONS <br />9 /7 �� � _-- <br />DATE SIGNATUREOFAPPLICANT � DAIE <br />PERMIT IS VALID FOR 1 YEAR <br />EXPIRATION � - ��_ � � <br />CALL FOR INSPECTION <br />POST ON 259-8811 <br />JOBSITE 24 HFiS. BEFORE CONSTRUCTION <br />