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everett APPLICATION FOR PUBLIC WORKS PERMIT <br />Type or prin� clearly wilh ink S3 a l� `, <br />� PRESS HARD - YOU ARE MAKING COPIES / <br />PERMIT NO. _�t-^'�"�'�`7 <br />PUBLIC WORKS <br />EVERETT, WASHINGTON BLDG. DEPT. NO.�p2 ?� <br />�OWNER ❑ AGENT DATE � J/�, .�� <br />APPLICANT/FIRM REPRESENTED _�"�'���'�,/�� �. �'//• �n:_'�- ____ __ <br />ADDRESS - ��� �'% ''/ ' 'I - "'�� " l��r''�. CITY '= ��/�- �' � TELEPHONE. � . + •� ' X 'Jk'� <br />HEREBYAPPLIESFORPERMISSIONTO ��%<' �Yi% `I _._._ �•� ',�1;•:- •trr.I <br />• nr...i :� f..�/_r.,A.�I , . <br />ATTHE FOLLOWING LOCATION _''' ti � -i(���� ��" � �� �- '�� � ' - �-. <br />Attach five (5) copies ot 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 normai 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 />CONDITIONS: <br />,�. <br />.1__ .._. . ,_ . . . . . . . . . . . <br />�...,..... . . . <br />l__..� _: .. . . . . . . .. . . . . . . . . . . . . . <br />l. . . . . � . . . � <br />I <br />'__.�.... ..._.'.. . . . � . � . . . . . . . . . . . . . <br />_._ � �.�. . . �. . . . . . . . . . . , <br />. . ..... i . . _ . - , . . . . <br />�-_,----;--- �--- - .- ; . - - . . . . <br />_.......�.,.... <br />�:_::: <br />� . . <br />l . . <br />l_ <br />�"i +'� ' / /4.� ��. ��lL--�...�t�.'� J i "r • c' �_. <br />PERMIT IS VALID <br />� EXPIRATION <br />The undersigned ownen c�reby agrees lo hold and save harmless <br />ihe City ol Everett trom any ana au clalms lor damages. cosis, <br />oxpenses, or causes of aclion that may arise becauso ol installalion <br />and maintenance of Ihe improvement ur olher righ��ol�way use <br />herelo apPlied lor antl lurlher agrees lo remova same upon nolice <br />Irom Ihe Ci�y and to replace public pmperty tlamaBed ihereby. <br />ACKNOWLEDGFMENT OF CONDITIONS <br />'d� <br />�_ <br />- SIGNATUREOFAPPLICANT DATE <br />1 YEAR pOS�� ON CALL F 5R�188 PECTION ', <br />JOBSITE 24HRS.BEFORECONSTRUCTION � <br />