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� <br />r. _. <br />"'°'"` APPLICATION FOR PUBLIC WORKS PERMIT <br />� TYPe or Print ele�Ay with ink ? <br />PRESS HARD • YOU ARE MAKING COPIES pERMIT NO. �� /� J <br />PUBLIC WORKS <br />EVERETT, WASHINGTON BLDG. DEPT. NO. <br />�OWNER ❑AGENT DATE S 'S -�Z- <br />APPLICANT/FIRM REPRESENTED �—' <br />ADDRESS ��'S�� �� � `� <br />HEREBY APPLIES FOR PERMISSIQ�� ?�� <br />AT THE FOLLOWING LOCATION <br />Attach five (5) copies of preiiminary <br />C''r`ti O �"� <br />� 3 �}iCu�1�o +-.1e <br />for proposed work <br />Y �`��« TELEPHONE � Z���� ob <br />`�4 0 �� � R uZ.0 ct.c.l S <br />����5 Q`e��c:�� <br />�v � � c �.� P 5'� <br />to scale and show the following as appHcable: <br />• Property lines and street identity. " Topographic changes requiring cuts and fills <br />• Outline and dimensions of existing and other than normal foundetion. <br />proposed structures. ' On-site drainage systems when required. <br />• Existing snd proposed utilities. ' Erosion control methods when required. <br />• Ce�terline of abutting right of way. • North arrow 1t <br />�%,�S t�C' �'tCC�-�a�- <br />SIO�eture of Applicant <br />PUBLIC WORKS PERMIT <br />4CQNDITIOPlS , _ _ <br />: I � (a(le� ,�;�w��- 6� . U��Cc�r�r� 1 -C-L �%i/ o� Cf�tSl�erY . <br />; . . . ; . .S��r i-�.�,�.ir� j . du(� co�;.rs = .;1c� -�ee-� w��c�e_ . : . . . . <br />. , , . . . -(-ro v.-� 3.�,� � lt' r. .5f. . •-t� I�i. l<�. 5 � c� � .�c: � . �-o �'. � . . <br />.- , <br />„ <br />._.��.-- - - • . . . .. --- -. . . . . ---_ . . . . . . . . . . . . . . ._ . . ._. . <br />.: ..�.... .. . <br />::.i.� l......... .. ,. ... ......... .... .. ..... ....... <br />I ' + <br />.� .. .:::::::::::: : �_'.:�� :: :::.:_+ ::T ::: <br />.., , �.... . . , . , . . . <br />..{. ,.... ..... ., ..,...,...�.. <br />. . <br />_ . , _. . . . . . . : , . , . . . . . . . . . . . . <br />_____ . . . . ._. . . . _ . . . . <br />_ 1 � . . _ . . . _ . _ . . . . . . : . .,� ____ . . . <br />I , � . � . ���.� . I . . , . <br />_ .. . � . .,. .i�. <br />_... ��r � .., .:�:..�. .,� <br />. ,... _ , ......... . . <br />E:: . L.: ��C �� S <br />I—__. __ . .lo� � �.M� /����.�' <br />,. :...V. �......... <br />�l �. . . . . . . . . . . . . <br />` • . . . . . ./_ . . . . . . . . . � . . . . <br />� <br />%���- s-./ •,-� <br />�PROVED FOR CONSTRUCTION DAIE <br />i. <br />APPROVED AS CONSTRUCTED DATE <br />PERMIT IS VALID FOR 1 YEAR <br />EXPIRATION �-�� �'3 <br />The undersiBned owner �ereby aB�ees to hot0 and seve hermlass <br />the qty of Everatl trom any ena en ueims ror Gmafla0. coat0. <br />expenses, or causes ol ectlon Ihet mey ariae because ot InslNlation <br />and meintenance of the improvement or other riq�tol�w�y uea <br />hereto applled for and furtl�er egrees to remove seme upon notica <br />Irom ihe City enO tc replaca public proparty damape0 ihereby. <br />�A OWLEDGEM TOFCONDITIONS <br />�lJ��.��.� <br />SIGNATUREOFAPPLICANT _DATE <br />CALL FOR INSPECTION <br />POST UN 259-8811 <br />JOBSITE 24HRS.BEFORECONSTRUCTION <br />i <br />�i <br />