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� <br />everett APPLICATION FAR P�1�3iLEC WORKS PERMIT <br />� TYre or Print clearlY wilh ink � <br />PRESS I1ARD • YOU ARE MAKING COPIES � <br />PERMIT NO. � � Z � <br />PUBLIC WCRKS � /�,/G/ <br />EVERETT, WASHINGTON �/D b„� BLDG. DEPT. NO. �` <br />O OWNER �AGENT DATE � <br />n v :� <br />APPLICANT/FIRM REPRESENTED <br />ADDRESS <br />0 <br />HEREBY API'LIES FOR PERMISSION TO <br />���_TELEPHONE 3'� 3 � yj��' <br />AT THE FOLLOWING LOCATION �C� � � <br />,_ �. � 1,�,:� /�r��/ <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 filis <br />' Ouifine 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 arrow <br />� / l� �3. .., � . <br />r.i.�, .r'�! r, l.._. ' �-L- - ._'__— <br />Signalure ol Applicanl <br />PUBLIC WORKS PERMIT <br />CONDITIONS: <br />. � :...:...:.:... �:,....... <br />, , __._ _. � . _ . . _ <br />i �r '� , . <br />'. �{:� � .. . '-. - . <br />, . ._ . -i ___ L. ._ - -_ __ . . _ . _ <br />{.�: }'+ .;f , ..i`.: .:' : ; ::: <br />, . � � t _ ._. . . . . . . . . ._ . . <br />t ' . .._. . .. <br />_ -� _ { `--_, -' , . . ; . . . . . . <br />:: �:: f :� '.: : : <br />, <br />- � � � � -- _ _______ <br />- , -. , � -1 .-; T -:--� _ <br />` .�, .1 .t ; � .: <br />� ,.. } ., � ��� <br />-� } -, ---,- -�- �� = . . _. <br />F.. . ; ,.. ,.. <br />•� ' ' <br />, {-- —_ � : . . I <br />i � i ; <br />. . . .-i-_ .� � . i . j . . � , j :. . . . <br />. . ; . . . � � . � � � . � . . : .. . : . . <br />..�::: � /��% <br />The unticrsi9neU ownen c�reby agrees to hci,: and save harmless <br />tho Gry ol Everelt trom any ana au ciaims lor damagas, cosis, <br />exPenses, or causos ol action �hat may adse because ot ins!ellation <br />- � nnd maintenance of �he Improvement or othar righ4ol-way use <br />� hurelo nppliotl for and turt�er agrees to remove seme upon notice <br />, - irom �he City antl to roplace pu611c property damaged Ih�reby. <br />-.!' Z <br />-- 7�Z/��Z <br />PERMIT IS VAL��-�OFi�YEAii <br />EXPI RATIOIV f"'� i-� 3 <br />ACKNOWLEDGEMENT OF CONDITIONS <br />�',v7! �rLC l� - � 1�/'� ' �7 G � �. . <br />SIGNATUREOFAPPUCANT DATE `\t� <br />CALL FOR INSPECTION <br />POST ON 259-8811 <br />JOBSIZ'E 24 HRS. BEFORE CONSTRUCTION ".i <br />e <br />� <br />