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� % <br />""'"` APPLICATION FOR PUBLIC WORKS PERMIT <br />Typa or print clearly wi�h Ink <br />PRESS HARD • YOU AP'. MAKING COPIES � Z <br />� PUBUC WORKS <br />' PERMIT NO. I O <br />EVERETf, WASHINGTON / BLDG. DC-P7. NO. °2 /�OI Y3 <br />❑ OWNER 6'AGENT DATE �- �' �� __ <br />, APPLICANT/FIRM REPRESENTED � on�it t ��yIFi3_ �pn5?, <br />ADDRESS �1��� E�iF��/iZtCti. G✓�y CITY Evf•4f7� TELEPHONE 3S�"���� <br />HEREBY AFPLIES FOR PERMISSION TO Co�-5T� �cT �c� ' C.i� d e AS�%: .sG % n��vr�✓A� <br />AT THE FOLLOWING LOCATION �S � y A�' 13 /'�� G��A.+cI iJr'iv,t _ <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 idertity. " Topographic char�ges requiring cuts and fills <br />" Outline and dimensions of existing and other than nonnal 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 />. --�5 �1� of APPlican� . <br />PUBLIC WORKS PERMIT <br />CON�ITIONS; <br />� I. —il�a.-� �o��io,.. o� -F��c e���..eway w.��,,. -��E �'.o.w: <br />j.::. w�H�� b� P����. I <br />I <br />' =::: a. <br />„. ._ ,_ <br />\\OOt.QOwS�o�v�5 S�.al� .OQ T15�+�'��htJ'I�i-q 0._ <br />c�r�wel� o� -+-�ec, ir }v -�-(�e SkPe-i SIio�w� dra�r, . <br />. . C. Cofr. �Itt�ic. Ci�a �n ��n�2. 15 1�o't" �-, ��.>.,v�� <br />� �n '11�e R. �.w.) <br />J -- - _ : <br />� ���� . . <br />�:" ;:::, :� . .I.: :._ <br />�- - ,_. . , <br />I`:Y': . <br />. . i ,Il/ . <br />, PERMIT IS VALID FdR 1 YEAR <br />. ��, EXPIRATION � /8- 83 <br />The undersignetl o�.vner here6y agrees to hold antl save hermlees I <br />Ihe City of Everett trom any anu au clalms for Cemepe4 cost0. i I <br />expenses, or causes of acHon that mey erlae becauee ol inslal;atlon <br />antl maintenxnce ol the improvement or olher dpht-ol-way uee � <br />hereto applietl tor and lurther agrees to remove e�me upon notice i <br />imm Ihe City aud to rnplace public property dama0� �heroDy. � <br />I <br />/ ACKNOWLEDGEMEMT OF•CONDITIONS <br />�/� I <br />/L' ��. i �,�.....,'� � � i�is.....,.-n-c__, - � <br />SIGNATUREUFAPPLICANT � DATE <br />f�OST ON CALL FOR Ii�SPECTION , <br />JOBSITE 259•8811 <br />24`HRS. B@FORECONSTRUCTION . �i <br />1 <br />�� <br />i <br />I� <br />