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-��� � � ,,��/ <br /> everett APPLICATiDN-F�Q1��UBLIC WORKS PERMIT- <br /> �l�tU l 1 I�x�'�IVY� <br /> � TYPe or print CICadY wilh ink <br /> PRESS HARD-YOU ARE MAKING COPIES �� S3 � <br /> PUBLIC WORKS PERMIT NO. . <br /> EVER' •' ', WASHINGTON BLDG. DEPT. NO. <br /> (3'bWNE7 ❑ AGENT DATE _ . _.� __�- r <br /> �'�/, c`}. <br /> APPLICANT/FIRM REPRESENTED _ _ --- �. —�:.f...- __�'_-- --- _---- —.------- I <br /> ADDRESS _ __!S _-J�_!�'� -�'• � CITY _' '— ___TELEPHONE : -: �i t i� <br /> HEREBY APPLIES FOR PERMISSION TO __� - �%' =_ _ __� ' ' �_��-<-� •.�%'! I <br /> — -- - ---- ---- — - <br /> AT THE FOLLOWING LOCATION _ ��_`�_U �( �°��"_�G� <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 identily. " Topographic changes requiring cuts and fills <br /> * v:�tline and dimensions of existing and other than normal foundation. <br /> S . 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 /> •,: <br /> '� —�-�---�-- � ----Signalmo of�ApPlicant--- <br /> `�. PUBLIC WORKS PERMIT <br /> I <br /> ,.CONDITIQNS: <br /> . <br /> -� � _� <br /> � N c, �- -1 �, ��k� � f� �.- s c� c:� c �� � �� �1 . <br /> L1 � ., �a �ebri� —}-fPcKp�, a„�.�o �-�ne Pc.�b � ic �� •V. � �� <br /> r w�u s�� b e �l P c. ,.. � �. ..._�� c�c. .1� <br /> �� U. � (O�ylon � CO✓t '{'KO� rb (C'` N� Cr � LM �[-l� � �C�N �a� IC `. �. cii �,< � <br /> �. : : �,� ���F�-� hr w.,���- �r � :� _\.�, \1 . ,�. .. � .. .._. .s . .. '�� . ., . `� <br /> - - '.,_ l, , � _ . 1 , � (�, . 1 � �, <br /> ,. � <br /> fn,• unticr,iyi�,�d uanci hereby aqrees to hold and save harmless <br /> mr Cdy ol Evcrett �mm any ond au ciaims for damapes, cosis, <br /> - • � � eapenses,or causes ol aclion Ihat may arise because ot installation <br /> - � • � • � - � � and maintenance ol Ihe improvemun� or other righPobway use � <br /> � � - herMo applied lor and lurther ngrees lo remove same upon noGce �, <br /> Irom ihe Cily and to replace public property damageE the�eby. <br /> / �C.f� / � 2�� y <br /> �� r����/ l6-ar�-�----"�'"a� .0 T' I <br /> ,�/{PPHOVED�STRUCTION DATE ACKNOWLEDGEMENT OF COIJDITIONS '�. <br /> APPROVED AS CUNSTRUCTED DATE SIGNATURE OF APPLICANT-' DATE <br /> PERMIT IS VALID FOR 1 YEAR pOST ON CALL FOR INSPECTION <br /> 259-8811 <br /> EXPIRATIpN l� �� � `� � JOBSITE 24 HRS. BEFORECONSTRUCTION <br />