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�everett pppLlCAi'iON FOR PUBLIC WORKS PERMIT <br />TYPC Or print clearly with ink �. /.J <br />PRESS HARD • YOU ARE MAKING COPIES J� ��-..p.:/ <br />PUBLIC WORKS PERMIT NO. _ � �S� � =% <br />EVERETT, WASHINGTON ; <br />❑ OWNER ❑ AGENT DATE _ �_____`__ BLDG. DEPT. NO. ;_'_= __ ' ___ <br />�- <br />� � _i <br />APPLICANT/FIRM REPNFSENTED _ __ '_�,_ ,-'� . ; , ;,�;- <br />�J . -� -. _ . _ _ . - — -- <br />ADDRESS � �._' / � �� G'�=_ �C __CITY �� - ; ;, � � TELEPHONE _--' � ;�_� 5�: , <br />HEREBY APPLIES FOR PERMISSION TO ___ <br />� �f-Y/� s'I'=i � <br />` _ r,� <br />AT THE FOLLOWING LOCATION ___ _<.�� _L'�� ��! _-.���__�'�_ /J�/ � /(/L .`- � :Y.' F-/ ; 1;J.,{� - <br />Attach five (5) copies of preliminary plans ior proposed work. Draw to scate 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 of way. <br />PUBLlC WO <br />CONDITIONS: <br />, � . <br />" Topographic chan;,;s �equiring cuts and filis <br />other than normal foundation. <br />' On-site drainage systems when required. <br />" Erosion contiol methods when required. <br />` North arrow <br />s: '�' - <br />�� <br />---- � - +� - -- � �- �— � � `� jir:.:', <br />--�� � � � S�gnalure ol AppNwnl <br />�KS PERMIT <br />The undwsi�nud owner hereby a9rees to holtl and save hurmless <br />U�c City ol Everett r�om any ano an daims br tlamages, costs, <br />erpenses. or causes of action Ihat may ar�se because ol inslallalion <br />antl maintenance ot Ihe improvement or ol�er rig�l-pl�way uso <br />heu;to apHPed lor and turlher agrees lo remove same upon notice <br />Irrm Ihe City an� lo replace public property domagetl Ihereby. <br />APPR VED FOR"CDNSTR CTION -UA7E ` ACKNOWLEDGEMENT OF CpNDITIONS <br />y/ (\ / <br />/ i�% / � `� � —�— - y� �j/�— � .� , _ � , <br />� . �, <br />APPROVED E9 Z) STRUCTED DAT�Y SIGNATUREOFAPPLICANT MDATE � - <br />PERMIT IS VALID FOR 1 YEAR <br />EXPI RATION <br />POST ON I CALL FOR INSPECTION <br />259-8811 <br />JOB5ITE 24 HRS. BEFORF'CONSTRUCTInN <br />