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�everett pppLICATION FOR PUBLIC WORKS PERMIT <br />TYPe or Prinl cleady with ink � <br />PRESS HARD • YOU ARE MAKING COPIES pERMIT NO. �� �� � <br />PUBIIC WORKS � <br />EVERETT, WASHINGTON � / BLDG. DEPT. NO. <br />O OWNER ❑ AGENT DATE —� � �" <br />APPLICANT/FIRM REPRESENTED �C�L�� SC. j� J L �/J � <br />ADpRESS <br />HEREBY APPLIES FOR PERMISSION TO <br />� CITY �` / � TELEPHONE�S��"-7S�J�J � <br />ATTHE FOLLOWING LOCATION ��a/�^�E___ �2�%J9' \c-f`��d 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. • Topographic changes requiring cuts and fills <br />` Outline and dimensions of existing and other than normal foundation. <br />proposed structures. ' On-site drainage systems when required. <br />" Existing and proposed utilities. • Erosiori control methods when required. <br />' Centerline of abutting right of way. * Nort� �arrow <br />�"'� � -��... <br />�.�G�-�._ � - <br />� � SignaWre oi ApPlican� <br />PUBLIC WORKS PERMIT <br />CONDITIONS: <br />, <br />,�. ;. . <br />i� 3 <br />�_<, :: �✓lo,�c,w.w�.. :�.�\ {� �c soo Y� <br />�_�.-. . . . . . <br />,.: .,,.. . <br />:;..:: t. '::::: <br />��_ � } .i :f ,; 1.�. :.. ;.. •.... � �....., <br />.... ,... ..�..... ... . . . ... <br />_. : . .4 �.�.� �— : . ; . . . : -_ __ . . . .. . . . . . . . . . : ._ . _ . . - � � . . -' ___ <br />,'- t -. . f � - . , ' . � <br />`_: T : _:__�.__ ' -.__. _. I <br />. a ,. � . <br />..._..!. ;.. . <br />_._,....i,.. .;..:;. <br />---r ��_._ s._,___• ; ; .. . <br />. • . _ . . . , . . { . . . . . . The untlersignea owner hereby agrees b noltl antl save harmless <br />. . . , . , � . . . . . . � , . _ , , Ihe City ol Evere11 Irom nny ana an cla�ms br damages, costs. <br />. . . . . . . . . . . . . . . . . . . . . expenses, or causes of aclion t�al may arise because ol Instal!alinn <br />� — - � � � � � • � - � � � � � � � - � � � - and maiNenenco ol Ihe improvement or o:her righPol�way use <br />. . . . . . . . . . . . . . . . h t f d t nd 1 th � n f <br />PERMIT IS VALID FOR 1 YEAR I <br />EXPIRATION <br />ere o epp ie or n ur er ugrees o remove same upo no ice <br />Irom Iho City and to replace public propehy damageC ihereby. <br />i•. <br />� ' <br />ACKNOWLEDGEMENT OF CONDI?IONS <br />1 � ' <br />�G�'�'� _ --- � l-� `��`r-- <br />$IGNATUREOFAPPLICANT DATE <br />CALL FOR INSPECTION <br />POST ON 259-8811 <br />JOBSITE 24 HRS. BEFORE CONSTRUCTION <br />