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<br /> everett APPLICATION FOR PUBLIC WORKS PERMIT
<br /> , � TYPa or print cluarly with ink I
<br /> PRESS HARD-YOU ARE MAKING COPIES pERMIT NO. g � � U�
<br /> PUBLIC WORKS I
<br /> EJERETT,WASHINGTON BLDG. DEPT. NO.f� d�4 I
<br /> � �OWNER ❑ AGENT DATE �1'1���� �� �
<br /> APPLICANT/FIRM REPRESENTED ���" '�r�S� � �
<br /> ,S� o'�-�, ' � Q � �3S?��36, I
<br /> ADDRESS �// � � � CITY GV�f"'t � TELEPHONE
<br /> � HEREBY APPLIES FOR PERMISSION TO C��1 S �"/G/ G / GJ /J � �/ f���'� �
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<br /> II ATTHE FOLLOWING LOCATION yaa � ��r�S ��.� � �� � II
<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 i
<br /> • Outline and dimensions of existing and other than normal foundation. �
<br /> ' proposed structures. * On-site drainage systems when required. �
<br /> � * Existing and proposPd utilities. ' Erosion conlrol methods when required. ;
<br /> � ' Centerline of abutting right of way. N9�a arro �` 'I
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<br /> ii SiBneture oi Applicant
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<br /> PUBLIC WORKS PERMIT
<br /> CO.NDITIONS: _ . . . . .
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<br /> �� : � : + , . , . . The undersigned ownar herehy aB�ees to hold and seve hermless
<br /> ; � ; , . , , . . Ihe City ol Everelt trom eny antl all cleims br demaBes, costa, I
<br /> � : . , . , , \ - expanses,or causes ol action thal mey erise because of Installalion
<br /> ' � v . - • and meintenance of lhe improvemont or other tlphFol�way use
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<br /> . . . . . . . , � � • � • � � horelo nppllad lor and furiher agrees to remove same upon notice
<br /> ' . . . , . � . . � � - � - � � � Irom tho City und to replace public proporty dameped thereby. I
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<br /> �� ..k ROVEDFORC NS UC '• DATE � �-.ACKNOWLEDGEMENTOFCONDITIONS I I
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<br /> � A PROVED AS CONSTRUCTED DATE SIGNATURE OF APPLICANT DATE
<br /> PERMIT IS VALID FOR 1 YEAR CALL FOR INSPECTION
<br /> POST ON 259-8811 �
<br /> EXPIRATION Sn., 1 �`183 JOBSITE 24HRS. BEFORECONSTRUCTION j
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