Laserfiche WebLink
� <br />everett '�APPLICATION FOR PUBLIC WORKS PERMIT <br />� . TYVe or Print cleadY with ink <br />PRESS HARD - YOU ARE MAKING COPIES <br />PUBLIC WORKS PERMIT NO. g� 3� L.? — <br />EVERETT, WASFiINGTON ,�/ � BLDG. DEPT. NO. Q � <br />❑ OWNER ❑ AGENT DATE 'C.�l/ Iy__�f __ _ <br />APPLICAN7/FIRM REPRESENTED <�{l�CLLCI� _r �LLl��[rJ�'/Z !L __ _____ _ <br />G ��'Jq� �1r�o <br />ADDRESS P___�� j—� �'_' 1u11i �—��� ._CITY C� %�/r� . TELEPHONE �v .c D`S�� <br />/ <br />HEREBY APPLIES FOR PERMISSION TO —__� � �=Ki �T�1��11•�� �[- �� <br />---- = V ��. <br />AT THE FOLLOWING LOCATION _��,%-.-{—�� f;z/�_fJJ-� +'- <br />� <br />Attach five (5) copies of preliminary plans (or 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 o( way. <br />CONDITIONS: <br />* Topograpliic changes requiring cuts and fills <br />other than normal foundatio�. <br />^ On-site drainage systems when required. <br />' Erosion control methods when required. <br />� North arrow <br />�c_�i.�c�:2i� i._-� , —' � �`� - --- <br />. . Sipnalure ol Applicant <br />PUBLIC WO�RKS PERMIT <br />.... . . G"". �, __ <br />i. � . <br />� �.- : _.. .- � ' j/ �� <br />� �/'� '-���;� Y�_!! —?� <br />PPROVED f0' i CONSTRUCTION DATE <br />APPROVED AS CONSTRUCTED DATE <br />PERMIT IS VALID FOR 1 YEAR <br />EXPIRATION <br />Tha undersi9netl owner �ercUy a9rees to holr' and save harmless <br />the Ciry ol Everell �mm any antl au cialms Iw damages, costs, <br />expenses, or causes of action Ihat may arise becausa ol inslallalion <br />and maiMenance of Ihe impmvement or olher righ4of�way use <br />hereto applied lor anC lurther agrees to remove same upon notice <br />trom Ihe Ciry and lo replace public pwperty tl::mag�.d thereby. <br />ACKNOWLEDGEMENT OF CONDITIONS <br />1��i .:� ',((-_•_: �=--.-rLi:. ' <br />�SI�Ca-NATU�EOFAPPUCANT DATE <br />POST ON I CALL FOR INSPECTION <br />259•8811 <br />JOBSITE 24 HRS. BEFORECONSTRUCTION <br />