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everett APPLICATION FOR PUBL�C WORKS PERM17 <br />� TYPe or Print clearlY with Ink <br />PRESS HARD - YOU ARE MAKING COPIES pERMIT NO. �� ��� . <br />PUBLIC WORKS q� � <br />EVERETT, WASHINGTON / BLDG. DEPT. NO.O <br />�,OWNER ❑ AGENT DATE _Sl S� �— <br />/ <br />APPLICANT/FIRM REPRESENTEO _ ��_fL_.�' ��/7 5 �' /� __.____ _ <br />. : -, <br />ADDRESS _�_"Q� �' /� ���• -- CITY ��•c'r r� TELEPHONE � � 1"! 5 G�� <br />�_-- _ if��� <br />HEREBY APPLIES FOR PERMISSION TO C,Y '{r� f�� �+ 4 � i' u t' <br />ATTHE FOLLOWING LOCATION � J5 /� �' �'� �r' <br />Attach five (5) copies of preliminary plans for proposed work. Draw to scale and show the following as applicable: <br />* Pr:,perty lines and street identity. <br />' Out�ine and dimensions of existing and <br />proposed structures. <br />' Existing and proposed utilities. <br />' Centerline of abutting right oi way. <br />PUBLIC <br />PERMIT IS VALID FOR 1 YEAR <br />E3tNIRATION <br />I:i <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 arrew �' <br />j� 7 i i �,,- � ,,�"v`- <br />PERMI'3' <br />� <br />:; �� . ,,- 7_ <br />:r �,__ <br />y _ �_.- ..1�. <br />... _:-F�-._ .- <br />,'�_ The undersigned owner hereby agrees to hold and save harmless <br />_ �� the Cily ol Everetl trom any antl an claims lor tlamages, costs, <br />' r- expenses, or causes of action that may arise because ol installation <br />� � and maintonance ol the improvement or other right-ohway use <br />-+ �-r- hereto apPlied br antl luriher agrees to remo�e same upon notice <br />-�-���-' Irom Ihe City and to replacr public propeAy Jamagetl thereby. <br />/ <br />," _ Z <br />� 7 ACK—� GEMENT F CONDITIONS — <br />fE � SIGNATURE APPLICANT DATE <br />CALL FOR INSPECTION <br />POST ON 259-8811 <br />JOF3SITE 24HRS.BEFORECUN��'RUCTION <br />� <br />