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r- <br />everctt APPLICATION FOR PUBLIC WORKS PERMIT <br />Type - Print clearly with ink a /��_ <br />PRESS BARD -YOU ARE MAKING COPIES PERMIT NO. t/L.-7-r <br />PUBLIC WORKS <br />EVERETT, WASHINGTON r ,1 BLDG. DEPT. NO. <br />B OWNER ❑ AGENT DATE <br />APPLICANT/FIRM REPRESENTED <br />ADDRESS V Zl - �AV�/ ✓ - CITY <br />HEREBY APPLIES FOR PERMISSION TO <br />A> <br />AT THE FOLLOWING LOCATION <br />2 -G <br />TELEPHONE �yJ—C7`'3L <br />G <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 />Si9nBture of Applicant �C' <br />CONDITIONS: PUBLIC WORKS PERMIT <br />_)U t,1 o•i- (e i <br />r'ct t' i VC r e �J/r f <br />CIrI /V t'r vsr C1 yr�i. rIl 0C �'4 ,Y`� ;�,541- Starr/[' J <br />� t�J�i/S fC i>,i %ICI >lt'�%J>R'�/>_>.. <br />��- � (,i?>/✓%�Gc i / tic �,�,£. Llic-; � S r.. �,� �� dam. .�, _, <br />C� A/�iGf cum /%✓iZ�r '� �4c' �n%/� � � t <br />I' The undersigned owner hereby agrees to hold and save `harmless <br />the City of Everett from any and all claims for damages, costs, <br />expenses, or causes of action that may arise because Of Installation <br />and maintenance of the improvement or other dght-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 />ACKN LEDGEMENT OF CO"TIONS O <br />SIGNATURE OF APPLICANT DA <br />PERMIT IS VALID FOR 1 YEAR I CALL FOR INSPECTION <br />POST ON 259-8811 <br />EXPIRATION JOBSITE 24 HRS. BEFORE CONSTRUCTION <br />