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7 <br />everett APPLICATION FOR PUBLIC WORKS PERMIT <br />Type or print clearly with ink <br />PRESS HARD - YOU ARE MAKING COPIES PERM'T NO. �2 I <br />PUBLIC WORKS <br />EVERETT, WASHINGTON BLDG. DEPT. NO. <br />❑ OWNER ❑ AGENT DATEb�7� <br />APPLICANT/FIRM REPRESENTED ��u„� C6 don -T ee') <br />ADDRESS ' /µu D 1— 5 CITY SAtd§TELEPHONE �%]Z5 �•> <br />HEREBY APPLIES FOR PERMISSION TO ekca lc pl6'd 4__T)i el < <'fi ^ TT <br />AT THE FOLLOWING LOCATION r3•S45 - 0n1?c'.] <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 />• Nortarrow <br />' 6 Z -b-2- <br />gnature of Applicant <br />PUBLIC WORKS PERMIT <br />The undersigned owner hereby agrees to hold and save harmless <br />the City of Everett from any and ail claims for damages, costs, <br />expenses, or causes of action that may arise because of Installation <br />and maintenance of the improvement or other right-of-way use <br />hereto applied for and further agrees to remove same upon notice <br />from the City and to replace public property damaged thereby. <br />WPR VED�FOR CONSTRUCTION DATE ACKNOWLEDGEMENT OFJCQNDITIONS <br />7 <br />APPROVED AS CONSTR TED DATE `SIGNATURE OFAWLICANT DATE <br />PERMIT IS VALI OR 1 YEAR pOST ON CALL FOR INSPECTION <br />259.8811 <br />EXPIRATION �- 1 - �� JOBSITE 24 HRS. BEFORE CONSTRUCTION <br />