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<br />everett pppLICATION FOR PllBLIC WORKS PERMIT
<br />� TYPe or pdnt cleadY wil� ink �� S 8 ..
<br />PRESS HARD-YOU ARE MAKING COPIES pERMIT NO.
<br />PUBLIC WORKS ON � &, � BLDG. DEPT. NO.�� �y3
<br />EVERETT, WASHINGT n� _ .q J -
<br />CJ QWNER ❑ AGENT DATE
<br />:ohL�:T ia, '3c,-�NSTo�
<br />APPLICANT/FIRM REPRESENTED � � �
<br />/�`�j'�C fl�l I� p� `S O i�) CITY �' �/�'` � TTELEPHONE ��i �`� � / �
<br />ADDRESS �% � � � -r
<br />HEREBY APPLIES FOR PERMISSION TO � C�U S� r� ��? C W�
<br />��� /V1 J��iso,�� S7 �v�+:'ET7—
<br />AT THE FOLIOWING LO�:ATION --�—
<br />Attach five (5) copies of preliminary p�ans for proposed work Draw to scale and show the following as aGP��cable:
<br />` Property lines and street identity.
<br />' Outline and dimensions of existing and
<br />proposed structures.
<br />" Existing and proposed utilities.
<br />* Centerline of abutting right of way.
<br />PUBLIC
<br />* Topographic changes requiring cuts and fills
<br />other than normal foundation.
<br />* On-site drainage systems when required.
<br />* Erosion control methods when required.
<br />* North arrow
<br />x �m � TniaNSTON —
<br />Signalure of ApPlicanl
<br />PERMIT
<br />CONDITIONS: --_ _ _ . -,-
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<br />,,__;��---^ --- , , : . ,, The undersigned owner hereby agrees to hold and save harmless
<br />' t '' the City ol Everelt Irom eny ana all claims for damages. costs,
<br />. , !-�.. ' • � � � ' ' ' _ ' : � � . , _ expenses, or causes of action ihal may arise because ol Instellation
<br />. . . . �. . :. . : . � . � � ' � . .....,_.._'.._'_'._'......'_ _ .. antl mainlenance of Ihe impmvemenl or other righ4ol-waY use
<br />� � � � � -�� ' � " � � � ' hereto apPlied lor and lurther agrees to remove snmo upon notice
<br />from the CiIY antl �o replace public p�oPerty demaged �hereby.
<br />'/-:'�� '-3-3 � -�3
<br />PERMIT IS
<br />EXPIRATION
<br />n
<br />�Vlc�
<br />D F�R 1 YEAR CALL FOR INSPECTION
<br />PQST ON 259•8811
<br />JOBSITE 24HRS.BEFORECONSTRUCTION
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