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APPLICATION FOR PUBLIC WORKS PERMIT <br />Type or print clearly with ink <br />PRESS HARD - YOU ARE MAKING COPIES PERMIT NO. a-' <br />PUBLIC WORKS <br />EVERETT, WASHINGTON // BLDG. DEPT. NO. <br />❑ OWNER i4 AGENT DATE <br />APPLICANT/FIRM REPRESENTED _k-RJj JQ0_P' ______ <br />ADDRESS S 1-2 —62 �jn uP -A) e CITY Jj�10TELEPHONE 6�'��C z <br />HEREBY APPLIES FOR PERMISSION TO°IroC1't'� f �IVu41 d i NSbV ti rv1i 0tfq hur,�PrS %ti Loovi41kci la �11 <br />ATTHEFOLLOWINGLOCATION /✓0✓11 ff 14 67 ddrkijC( 5LlVff!17S ICVPvP?1 J u'01iC I1'I06,14rrfJt <br />e2 F6 r G, '-L <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 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 foundation. <br />• On -site drainage systems when required. <br />• Erosion control methods when required. <br />• North arrow <br />..-•--^--r'- i �T T.,'. '�_..�1--i ram. <br />/�—r3v� <br />i <br />j <br />! -.1 The undersigned owner hereby agrees to hold and save harmlM <br />_ i I { I f� i the City of Everett from any and all claims for damages, coats, <br />expenses, or causes of action that may arise because of Instal lon <br />-1� and maintenance of the Improvement or other right-of-way uN <br />--{ hereto applied for and further agrees to remove *a" upon notim M <br />i from the City and to replace public property damaged ereby. <br />-c—_Z R �� 7 <br />OVED FOR. NST ION DATE "\ ACKN WLEDGEMENT OF ITIONS <br />D AS CONSTRUCTED DATE SIGNATURE OF l- A DATE <br />PERMIT IS VALID FOR 1 YEAR fr;.ALL FOR INSPECTION <br />POST ON 259•SSI I <br />EXPIRATION JOBSITE 24 HRS. BEFORE CONevTRUCTION <br />