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e�e`e" qppLICATION FOR PUBLIC WORKS PERMIT <br />� TYPo or Prinl clearly with ink Q <br />PRESS HARD • YOU ARE MAKING COPIES pERMIT iVO. V`� 1� � <br />PUBLIC WORKS <br />�EV El"f, WASHINGTON � BLDG. DEPT. NO. _ <br />WNER ❑ AGENT DATE .�,/�___� f 'y7^ <br />APPLICANT/FIRM REPRESENTED —Yl!_��L�%'� /'- �'"�`//`"� ^+—' �'������� <br />ADDRESS _vC�7���� �/�`�—� ��� ` CITY L�� TELEPHONE -�S 3���I'� <br />HEREBY APPLIES FOR PERMISSION TO ��/ ��" <br />/'cf.t�tC��n.c�% .�'r_r.�f �c- �O�C�''�t'.� <br />`� 07�//� <br />ATTHE FOLLOWING LOCATION <br />� <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 contral methods when required. <br />' Ce�terline of abutting right of way. ' No rr�.-'� ;., <br />�s �� � � <br />Signature ol Applicant <br />PUBLIC WORKS PERMIT <br />DA <br />PERMIT IS VALID FOR <br />EXPIRATION <br />L'Z <br />� i�# : . : .}_ �: r_�. � _ <br />The undersigned owner hereby agrees lo holtl and save harmless <br />(he Cily ol Everelt Imm any ana eu claims lor dama0es, cosls, <br />exDenses, or causes ol aclion Iha� may arise because ot inslellation <br />entl mointenance ol I�e improvemenl or ather nB��-ol�way use <br />hareto applietl br and lurther agrees lo remove same upon notice <br />Irom the Ciry ana to repleco public pmporty dameged Ihereby. <br />`�� ACKNOWLEDGEMENT OF CONDITIONS <br />SIGNATUREOFAPPLICANT DATE <br />CALL FOR INSPECTION <br />POST OM 259-8811 <br />JOBSITE 24HRS.BEFORECONSTRUCTION <br />H V- <br />y , <br />H . <br />� � <br />r <br />� �. <br />� � <br />l'1 '_ <br />Cy �� <br />H H <br />O; <br />� " <br />� <br />c`, <br />� <br />a <br />�:, <br />