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odr <br />APPLICATION FOR PUBLIC WORKS PERMIT <br />or Print clearly with ink PRESS HARD <br />- D -YOU ARE MAKING COPIES PERMIT NO. <br />PUBLIC WORKS BLDG. DEPT. NO. <br />EVERETT, WASHINGTON _[J <br />❑ OWNER ❑ AGENT DATE cam, <br />APPLICANT/FIRM REPRESENTED if < y✓ <br />ADDRESS 5 M/ayi <br />CITY TELEPHONE <br />��i� /K 'Jr//� �/gi.nac•C <br />HEREBY APPLIES FOR PERMISSION TO <br />Y(2�iv c .1� PKIP <br />AT THE FOLLOWING LOCATION <br />Attach five (5) copies of preliminary plans for proposed work. Draw to scale and show the following as applicable: <br />cuts and fills <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 />BLI <br />CONDITIONS: <br />N <br />APPROVED AS CONSTRUCTED DATE <br />PERMIT IS VALID FOR 1 YEAR <br />EXPIRATION <br />• Topographic changes requiring <br />other than normal foundation. <br />• On -site drainage systems when required. <br />• Erosion control methods when required. <br />• No brro t t <br />Signal re pl APPIIcaM <br />The undersigned owner hereby agrees to hold and save harmless <br />the City of Everett from any and an claims lot damages, costs, <br />expenses. or causes of action that may arise because of installation <br />of the Imro <br />hurcto ause <br />andlpplied ntenance for and further agrees to removersamet uponanotice <br />from the and to replace public Property damaged thereby. <br />ACKNOWLEDGEME T FCONDITIONS. <br />SI NATURE OT PPLICANT <br />?OST ON <br />JOBSITf= <br />CALL FOR INSPECTION <br />259-8811 <br />24 HRS. BEFORE CONSTRUCTION <br />