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<br /> j APPLICATION FOa PUBi_IC WORKS PERMIT
<br /> � Typa or print dearty with ink '
<br /> \I PRESS HARD-YOU ARE MAKING COPIES �/ i 3
<br /> PUBIIC WORKS PERMIT NO. 6 ' _
<br /> EVERETT,WASHINGTON BLDG. DEPT. NO.___ �1
<br /> ❑ OWNER ❑ AGENT DATE �—� -� I
<br /> APPLICANT/FIRM REPRESENTED �s_L+� S'fn/�L,�-
<br /> ADDRESS y-Z %' /�E'c.F� Diii�c CITY �ur�-c 77� TELEPHONE -�� J'-�c%;['
<br /> HEREBYAPPUESFORPERMISSIONTO L�3ct/�c/ ��t���iG �e' . �o �r Ff��. ' nio
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<br /> ATTHEFOLLOWINGLOCATION yZ�� ���'/F ', n'';✓�
<br /> Attach five(5)copies of preliminary plans for proposed work Draw to scale and show the following as applicable:
<br /> " Prope-ty lines and street identiry. ' Topographic changes requiring cuts and filis
<br /> " Outline and dimensions of existing and other than normal foundatfon.
<br /> proposed structures. • On-site drainage systems when required.
<br /> • Existing and proposed utilities. ` Erosion control methods when required.
<br /> ' Centerline of abutting right ot way. * North arrow
<br /> /1 r�ni,/�i—c
<br /> - ipnature ol Applicant—
<br /> PUBLIC WORKS PERMIT
<br /> CONDITIONS: . _ _ .. . ___ . _ _-_ . _
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<br /> � �-,rt���� ,� ; ��� ,^���_-�—r--.- � The undersifned owner here6y agrees to hold and save hermless
<br /> , , , , ; , , ; , , , , , , , , , � . . . � . . . . the City ol Everett trom any ana eu cieims for damape0. costa
<br /> , , , . . . . . . . . . . . . . . . . . .# . . . . ezpen5e5,or cnuses of atlion t�at mey Brise bacau6e Of inatalletion
<br /> . . ... . . . . . . . . . . . . . . . . . __...., .___ . . antl maintenenCe ot the ImOrovement of ot�er dOht-o4Way u6e
<br /> � . . . . . . . . . . . . . . . . . . . . . . hereto applied lor and lurther agrees to remova same upon notite
<br /> ;i � - � � � � � Irom tha City anC to replece Oublic property damefleG ��ereby. �
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<br /> /A�PRf1VC-� FOR STRUCTION . DATE ACKNOWLEDGEMENTOFCONDITIONS �J
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<br /> APPRO AS' ONS RUCr D DATE SIG ATURE OF CANT DATE
<br /> PERMIT IS VALID FOR 1 �EAR pOST ON GALL FOR INSPECTION
<br /> EXPIRATION f � �-3 JOBSITE 259-8811
<br /> 24 HRS. BEFORE CONS7RUCTION
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