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<br /> � pPPLICATION FOR PUBLIC WORi S PERMIT I
<br />� � TYGe or Pdnt clearlY wil�Ink I
<br /> PRESS HARD•YOU ARE MAKING COPIES pERM1T NO. -----�—
<br /> �
<br /> PUBLIC WORKS BLDG.DEPT. NO.�— I
<br /> EVERETT,WASHINGTON � � _ ��
<br /> �GENT DATE �— �
<br /> ❑ OWNER ['t �
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<br /> ApPLICANT/FIRMREPRESENTED S/f{,?-SI�� I
<br /> r , , c , ' CITY '� �.,'�`—TELEPHONE�.-- �
<br /> I� ADDRESS /i�Fi� :! v�-._,� I, %�". - I
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<br /> 1-f-�SY'a G� �/,^ �•ir�r r J¢C � �' . �I
<br /> I HEREBY APPLIES FOR PERMISSION TO / �
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<br /> I AT THE FOLLOWING LOCATION �
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<br /> Attach five(5)copies of preliminary p�ans for proposed work Draw to scale and show the following ts applicab e: I
<br /> � Property Ifnes and street identity. 'Topographic changes requiring cuts and fills I
<br /> other than �ormal foundation. I
<br /> � Outline and dimensions of existing and . On•site drainage systems when required.
<br /> proposed structures. � Erosion control methods when required. �
<br /> • Existing and proposed utilities. . yarth arrow _ I
<br /> • Centedine of abutting right of way. i•- � �_-._,
<br /> � -r- �
<br /> Sfqnature ol PPPlicanl �
<br /> PUBLIC WORKS PERMIT j
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<br /> � CONDITIONS: . - - _ . . .__ . . _ . . . � . . . : . . . . . . i
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<br /> The undersigned awner hereby agreea to hold end save harmie6s
<br /> I �,i"'"?—'f�' . • !' �he City oI Everetl Iwm eny ana au clelma lor dema0e0. coet0.
<br /> I . �� i : ., , � . . . � � .- - . Y: expanses,or causes ot action Ihal mey adae beceuee ol inet�ll�tlo� I
<br /> , i � 1 � and meinlxnance ol 1he Improvement o� ol�er rl9ht-of-wey uee I
<br /> � - � � � � � ' � � � hewlo epplied for and lurlher eB�een to�amove eame upon notlee I
<br /> I , : � �'" � , . � iram ihe Cily end lo re0�ace pu611c properlY demaped �hereby.
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<br /> � ��^�f DATE ACKNOWLEDGEMENT OF CONDITIONS �
<br /> 1'� , PPROVEDFORC STRUCTION , _ �--
<br /> '� DATE SIGNATUREOFAPPLICANT
<br /> DATE I
<br /> APPROVED AS CONSTRUCTED CALL FOR INSPECTION I
<br /> � . �� PERMIT IS VALID FOR 1 YEA pOST ON 259•8811
<br /> �j/a ,�X/�����Oi° �� � � JOBSITE 24 HRS.BEFORECONSTRUCTION i,
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<br /> EXPI
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