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r <br />�e°°re" '' APPLICATION FOR PUBLIC WORKS PERNi1T <br />TYPe or Print clearlY wit� ink <br />PRESS HARD - YOU ARE MAKING COPIES pERMIT NO. $�/I �I S <br />PUBLIC WORKS �., ��.,�,� <br />EVERETT, WASHINGTON // BLDG. DEPT. NO.��� <br />❑ OWNER f3�AGENT DATE _NJ1��� ___ <br />APPLICANT/FIRM REPRESENTED <br />ADDRESS /� � (F_ � � ,,, lL���� ;,ITy �✓.e �- < 7% TELEPHONE a f�i - i5'72 <br />HEREBY APPLIES FOF PERMISSION TO <br />AT THE FOLLOWING LOCATION �7 3 � iP4 , i� � � /� !� � � r„ l-� � ��r %/�' � <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. • Erosion control methods when required. <br />` Centerline of abutting right of way. • North arrow <br />�n,�.z�- ��,t�� . <br />� SipnaturBolAPDlicent� <br />PUBLIC WORKS PERMIT <br />:-. ��;�1_:-.__ <br />The undeisignad owner hereby agrees �o hold ana seve harmlens <br />t�c Cily ol Everell trom any eno ail clalms lor damapes, coats, <br />expanses. or causes ol aclion that may arise beceuse of Inetslletlon <br />and meintonance of ihe improvement or other nght•ol•way uee <br />horeto applied lor and luriher agrec � lo remove sama upan notice <br />Iwm Ihe Ciry and to replaca pubh� proDeAy damaped t�ereby. <br />vrrnvvcurVMl:VNSIHUGIWN DA7E ACKNOWLEDGEMENTOFCONOITIONS <br />� I �, ��� ��� G''G� �—� ��./i�G���� Z��C/'�J <br />4PPROV �SCONSTRUCTE DATE SIGNATUREOFAPPLICANT DATE <br />PERMIT IS VALID FOR 1 YEAR �ALL FOR INSPECTION <br />POST ON 259-8811 <br />EXPIRATION JOBSITE 24HRS.BEFORECONSTRUCTION <br />� <br />� <br />