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<br />� �'` APPLICATION FORp�2,� �G' W�KS PERMIT
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<br /> � PRESS HA - OU ARE MAKINO��IES .� �Z�
<br /> I PUBLIC WORKS � pQ� 1� ��� PERMII' NCI. _
<br /> E\�ERETT,WASHINGTON ` JER �, BLDG. �F?T!�N���vv� ""�
<br /> rJ OWNER ❑ AGENT DATE -_� %�- k •'� . -' F � VeP � I
<br /> �., �...G�,�,� O�ocws � ,
<br /> APPUCANT/FIRM REPRESENTED �i���%::-2-�='/�- ey'"i�-'����-"`-° tic.f-�-'
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<br /> ADDRESS ,��'S�/1 � /�G���-'Cv CITY ��'�`��('ll TELEPHONE -��— � �
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<br /> HEREBY APFLIES FOR PERMISSION TO ��/�1 /`:'i �' i/lfi �c . �-�- � .-c slC.�=�-t t-t� �rl�'�'`J
<br /> AT THE FOLLOWING LOCATION ������ ����1��"�
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<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 identiry. " 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 /> I * Existing and proposed utilities. " Erosion control methods when required.
<br /> ' Cen!erline of abutting right of way. ` North arrow
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<br />�'I PUBLIC WORKS PERMIT
<br />' CONDI.TIONS: _. .
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<br /> . , , , , . , , { , , , � , , , � , , . . The undersigned owner hereby agrees lo ho10 and save hermleas
<br /> � � � ' Ihe Cit of Everelt trom any ano an clalms for dama0es, costs,
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<br /> ezpenses,or causes of aclion Ihel mey arise beceuae ol inatelletlon
<br /> . . . . . . . . . . . . . . . . . . . . .. . . . . . . . entl maiMenance of ihe improvement or othar rig�4o1-way use
<br />� . . . . . . . . . . . . . . . . . � hereto apP��ed lor eod further agrees to remove seme upon notice
<br /> i � � � � � � / -� � � � � imm Ihe City and to replece puhlic p�operty dameped l�ereby.
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<br /> A( ROVED FOR CONSTRUCTION 7ATE ACKNOWLEDGEMENT OF CONDITIONS �
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<br /> AP R E ASC TRUCT DATE � SIG�REOFAPPLICAN DATE
<br /> PERMIT IS VALID FOR 1 YEAR pOST ON CALL FOR INSPECTION 3
<br /> // / 259-8811 ty
<br /> EXPIRATION , —�` - '�� JOBSITE 24HRS. BEFORECONSTRUCTION
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