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IN <br />a <br />L <br />APPLICATION FOR PUBLIC WORKS PERMIT <br />Type or print clearly with Ink <br />PRESS HARD - YOU ARE MAKING COPIES �.` <br />PUBLIC WORKS PERMIT NO. <br />EVERETT, WASHINGTON <br />*OWNER ❑ AGENT DATE Z BLDG. DEPT. NO._ <br />APPLICANT/FIRM REPRESENTED <br />ADDRESS e� eC4e tr�e CITY <br />HEREBY APPLIES FOR PERMISSION TO � diY /C!!/i/q <br />AT THE FOLLOWING LOCATION <br />TELEPHONE <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 �rr�oy,�,�� ;%/Lt.✓rrw <br />Siglisture of Applicant <br />PUBLIC WORKS PERMIT <br />CONDITIONS: <br />. . . . . . . <br />. . . . . . . . I - <br />The unde,signed owner hereby agrees to hold and save harmless <br />the City of Everett from 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 />ACKNOWL�f3EP�"E�N/T OF CONnITIONS <br />SIG NATUR OF Afs�LICT �yE <br />PERMIT IS VALID FORA YEAR CALL FOR INSPECTION <br />POST ON Ill. 259-8811 <br />EXPIRATION I JOBSITE 24 HRS. BEFORE CONSTRUCTION <br />1 <br />j <br />