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` <br />�"e`e" APPLICATION FOR PUBLIC WORKS PERMIT <br />� TYPc or P�int cleedY wilh ink 6 / <br />PRESS NARD - YOU ARE MAKING COPIES pERMI i NO. _9��+ — <br />PUBLIC WORKS - <br />EVERETT, WASHINGTON BLDG. DEPT. NO.__ a ° 3% <br />❑ OWNER ❑'AGENT DATE — _, __— - _ <br />� :�j. s : ' - <br />APPLICANT/FtRM REPRESENTED =—= ------ --- - <br />---- "-'-- -- - <br />���— ' ' ,ys� � i <br />ADDRESS — ' � ����" CITY � ���r' TELEPHONE � �� <br />� <br />i .' � <br />HEREBYAPPLIESFOR'rERMIS510NTO ,'�'f��`r'�`-�''^ " J�— <br />�' <br />� ;� '"' ;;. <br />. .. . i'1•, . , . — ---- <br />ATTHE.FOLLOWINGLOCATION _��/� — O CPQ„ �tfe'-'-- <br />Attach five (5) copies of preliminary plans for proposed work. Draw to scale and shovi the following as applicable: <br />• Property lines and street identity. <br />* Outline and dimensions of existing and <br />proposed structures. <br />• Existing &nd proposed utilities. <br />` Centerline of abutting right of way. <br />CONDITIONS: <br />' Topographic changes requiriny cuts and fills <br />other ihan rormal foundation. <br />' On-site drainage systems when required. <br />` Erosion control methods when,required. <br />` North arrow _ <br />-'- -� --�- - ' --� � Si�nalure ol APPlicanl ! <br />LIC WORKS PERMIT <br />�j 1��.�- �or�'��.-. o-� '�� e cifi., e ...o.� �.: ( -�1. �. <br />�\iNT O` V�a� MNS� bE PQ�+nc... <br />R�oF -�� • ti ' <br />ct � a. �„ e �..., �. � b_ ra., iro � 1. � �.. .�. t. �. <br />1�� of "1-��\.}� �,�.-.�. �..�.o -'�fo��.. I?ru�.� �-.�S�e,.� <br />�__— � <br />ii ��;� <br />ii.� <br />0 � <br />--ti/�l� z-- <br />PERMIT IS VALID FOR 1 YE/1R <br />�- `�- k� �' <br />EXPIRATIOiV — <br />ihv unJeisgi �=� ownC hCreby a9mes lo hold and save harm�ess <br />the Gty ol Eve�etl trom ony ana au claims lor damages. costs, <br />erpenses, or causos of acliun Ihnt may arise because ol inslallation <br />and mninlonance ol the improvemenl or other righ4obway use <br />hereto applied lor and lurlher a9rees to remove same upon nolice <br />Irom 1he Ciy antl �o repiace public pmperly damaged thereby. <br />ACKNOWLEOGEMF.NT OF CONDITI- NS <br />/ <br />.",�� � .�( - ,_� <br />; , � r . �._ " � _ -- <br />. SIGNAiUREOFAPPUCA 1 DATE _ <br />CAL.L FOR INSPECTION <br />PC�ST ON 259-8811 <br />JOBSITE 2g HRS. BEFORE CONSTRUCTION <br />