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i <br /> everett APPLICATION FOR PUBLIC WORKS PERMIT <br /> I � TYPe or prinl cleadY wit0 ink <br /> PRESS HARD -YOU ARE MAKING COPIES pERMIT NO. �'� 3 � � <br /> PUBLIC WORKS <br /> EVERETT, WASHINGTON BLDG. DEPT. NO. <br /> E+rOWNER ❑ AGENT DATE _q.�a�l�Z_ <br /> , J tJ � ,� <br /> APPLICANT/FIRM REPRESENTED v�=N___ /` � N C� <br /> ADDRESS �' UG� �OL.L ��� .v�U� CITY �V �E�TELEPHONE_c�.��,� � 63I <br />� HEREBY APPLIES FOR PERMISSION TO ���I�— � �p� �/� G�U�� <br />� ��I+� 1a C� �S.0 T_y��-�-- <br /> ATTHE FOLLOWING LOCATION _�J_G���e �-S �pVB <br /> I Attach five(5)copies of preliminary plans for proposed work. Draw to scale and show the following as applicable: <br /> I <br /> I� ' 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 /> i - ' Existing and proposed utilities. * Erosion control methods when required. <br /> • Centerline of abutting right of way. ' North arrow , <br /> i � <br /> I —_ / ' �c,• <br /> � Signe ure ol Ap lican� <br /> coNoiTioNs: PUBLIC WORKS PERMIT <br />' , � � � i �. <br /> I .. .'_. i j..... I_ .�i.J � � •__�".. '�.. . � - � b' <br /> � �.�T � e <br /> � t _t ��; �� ' a C � <br />� � ,j t_ , � ,._. � � � I , �, U`' <br /> _;T���,._�:_ I e G �� i <br />; 1 , i �...� 1_;. � � � � � � � �y, � f <br /> ; �- � �_� �(r o� q <br />'r �.±{�!� i ` ��.. � � � � ./f <br />� � l.. ` � y � �i .. <br /> 1 I I i_� ' � d C ��. � I/�N <br />� -C-. �-� � ;� _. _ L ►� ; I " � ` �` <br /> , <br /> � � ` i1 � ' <`' I � Cl � /� C' � � <br />'� � r �-*,i1 { � � ( J I <br /> � �� ':.� � ' ' ` ~ ' ��' I � e �( / es e " <br /> i.1. <br /> � � a �, � U <br />, , , �, { :.. i � <br />� �I � � j �_ .5 0 �;Y <br />� 1 � i-.1 � � � �1_! � �� � The naersignetl owner hereby agrees lo hola and seve �armleas <br /> i. .�..� i � f ��� the Cily of Everett iwm any eno au claims for dameqea, coste, <br /> 4 �-- i�--j-1- 1-'�-'•- expensos,or wusos ot action that may arise baceusc M inetelletion <br /> , . t , , . antl mainlenance ol t�e imD�ovament or olher nr•;it•oFwey uee <br /> � � �� � � � � hereto applied lor and lurt�or eBrees to remove�a�ns upon nolfce <br /> I Irom the Cily antl to replace public property dame0� Ihareby. <br />� <br /> APPROVED FOR CONSTRUCTION DATE ACKNOWLEDGEMENT OF CONDITIONS � <br /> APPROVED AS CONSTRUCTED DATE SIGNATURE OF APPLICANT DATE <br /> PERMIT IS VALID FOR 1 YEAR pOST ON CALL FOR INSI'�ECTION <br /> 259-881 ! <br /> EXPIRATION JOBSITE 24HRS. BEFORECUNSTRUCTION <br /> i � <br />