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<br />everett �pp�ICATION FOR PliBLIC WORK� PERMIT
<br />� TYPa or Prinl GoarlY wilh Ink /
<br />PRESS HARD - YOU ARE MAKING COPIES pERMIT NO. ��i `'--��"
<br />PUBLIC WOiiKS
<br />EVERETf, WASHINGTON ,.,_, BLDG. DEPT. NO._
<br />❑ OWNER ❑ AGENT DATE �� �"� ���
<br />APPLICANT/FIRM REPRESENTED -� ' i J r' r F-� "�%� �
<br />ADDRESS �� � � �• /3 rr� U� uJcv cI �"'�}' �Z CITY _�' '�TELEP'riONE 3 S'.i^j"o YO
<br />HEREBY APPLIES FOR PERMISSION TO ' ��� ` t�'�J '� �'i � �' u 'r ;i� �[ ; d i-: � • � _
<br />ATTHE FOLLOWING LOCATION ���� � /j��""�
<br />Attach five (5) copies of preliminary plans for proposed work Draw to sr;ale and show the following as applicable:
<br />t 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 />* Topographic changes requiring cuts and fills
<br />other than normal faundation.
<br />' On-site �irainage systems when required.
<br />� Erosion control methods when required.
<br />* North arrow
<br />-L':�- ..'-'�_ i.�'1;. ;.� ��i,.,�
<br />SigneWre d( Applicant
<br />pUBLIC WORKS PERMIT
<br />C.ONDITIONS: "
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<br />� '-"jY � � ' . The undersi9netl owner hereby agrees to hold and seve harmlesy
<br />' �� Y �'• ���� �, � � . ihe City ol Everett trom any ena au clalms for dameges, cosis,
<br />�i , -' � � : � _ , � � ,. ., . � ,. .. . . expenses, or causes of action tha� may arise bocause ol ins�allation
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<br />� ,y , ., _ , ,. ,____ ._. __.. . . and maintenance ol tho improvemunl or other tlgh4obway use
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<br />� � hereto apPlied lor and Wriher agrees to remova same upon notice
<br />I ,, .. .. . Irom �he Ciry and ro replace public pmperty damaged Ihereby.
<br />I `%/'��'`�'/-'/ 7- �—/,'-0'�-
<br />DATE �
<br />� ACKNOWLEDGEMENT OF COND�TIQNS
<br />'� . . f _ ' ,1C �..�� � ' � �
<br />.;,,., ,�� �-� ��� � ,�� �;; �,�
<br />�ATE SIGNATU�.iEOFAPPLICANT DATE
<br />IS VALID FOR 1 YEAR
<br />ExPIRATION
<br />POST ON
<br />JOB�ITE
<br />__. _ _.____
<br />CALL FOR INSPEc i wn
<br />259-A811
<br />24 HRS. BEFORECONSTRUCTION
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