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eV� �4PPLICAI �ON FOR Pl76LIQ�WiO,��� e�111417 <br />Type or print cleady with in , �� J �} '�: I � <br />PRESS HARD - YOU ARE MAKIII OPIES U �-� '' <br />PUBLIC WORKS J���,� 1 S���T NO. ���� _ <br />EVERETT, WASHINGTON BLDG. DENT. NO.�J�6�3 <br />�OWNEN OAGENT DATE �Il�IPi2 ........ ................................................... <br />,�- n n CITY OF EVERET'i <br />APFLICANT/FIRM REPRESENTED /�'�' � � �'�'�'"� V�'crks D_r'____ <br />ADDRESS7s0�' Lp-�^�'P,t' (�,���'-�- R�. CITY t� TELEPHONE �'S-3' 9�!�d <br />HEREBY <br />A <br />- � __ -i . - — -- - - <br />Attach f!ve (5) copies of preliminary plans for propose:; work Draw to scale and show the following as applicable: <br />* Property lines and street identity. <br />' Outline and dimensions of existing and <br />proposed structures. <br />' Existing and proposed utilities. <br />* Centerline ot abutting right of way. <br />PERMIT IS <br />EXPI RATION <br />* Topographic changes requiring cuts and fills <br />other than normal foundation. <br />• On-site drainege systems when required. <br />* Erosion control melhods when required. <br />* North arrow <br />NY�tV tiC . �i;L�-r� <br />� SlgnaNre ol Applicant T <br />PUBLIC WORKS PERMIT <br />FOR 1 YEAR <br />The ��ntlersigned owner hereby egrees to hold and save hermless <br />iho City of Everett trom any antl all clalms lor demages, cosis, <br />expenses, or ceuses oi actlon that may erisa because of Inslallation <br />end maintenance of Ihe improvement or other righl-oi-wey use <br />hereto applietl lor and lurihar egrUes to remove same upon notice <br />Irom the City and to replace public p!operty Camoged thereby. <br />iE ACKNOWLEDGEMENTOpFCONDITIONS <br />�� _ z s _�v �,f � � oZ . ��., ����.a �� <br />fE SIGNATUREOFAPPLICANT �D T-�- <br />POST ON CALL FOR INSPECTION <br />JOBSITE 259•8811 <br />24 HRS. BEFORE CONSTRUCTION <br />