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'�"en ' APPLICATION FOR PUBLIC WORKS PERMIT <br />� TYPe or prin� clearlY with ink <br />PRESS HARD - YOU ARE MAKING COPIES � <br />PERMIT N0. �� � �� <br />PUBLIC WORKS � <br />EVERETT, WASHINGTON O <br />❑ OWNER ❑ AGENT DATE ___`=.3�- �/ _ BLDG. DEPT. NO... n�!' <br />APPLICANT/FIRMREPRESENTED __Q�EWGA.Jp LJ_�(,��[t'c��TIJ�/_�O,_y�_�,_ __ <br />ADDiiESS �`' i� ��O,C � CITY �C✓�REiT TELEPHONE � � i - %� /� <br />HEREBY APPLIES FOR PERMISSION TO _ USE C�iT Y�(/�T- U�' ,1/q � <br />�'11),�R� .�.� - i? � F, o,��c,� �--� o,y �QOCKEFEGLE�P AvE <br />ATTHE FOLLOWING LOCATION �b<� `% ,���KFF'!" � _ .� ,- � <br />, L.LL�.. _ <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 identity. " 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 />' Existing and proposed utilities. '� Erosion control methods when required. <br />• Centerline of abutting right of way. ' North arrow <br />. - ,, <br />—� � � �J�._��.. _ „ <br />SignaWre ol Applicant <br />PUpLIC WORKS PERMIT <br />CONDITIONS: <br />� i��„ 'te. l N� PLi\!� �-�{C, <br />�. SI G!J - GOIJST�TZUC,T I D�'J <br />�`�(�L!_<_ '..t.' llj(� <br />A�CP�� <br />; <br />�:::: : . <br />' 61JE SIC�{� I�iC2T F-� _� �:^U�1-� %: C <br />� L. . $ � I t� , <br />7�tf FF/� /n/<�i"; j <br />/ ,' <br />PERMIT IS VALID FOR 1 YEAR <br />EXPIRATION �n'/ l � ' '�' <br />ihe u.Jcisiqned owner hereby a9recs Io hold and save harmless <br />thc Gly o� Everett trom any and an cla�ms lor dema8as, costs, <br />expenses, or causes ol action Inat may arise because of instellalion <br />antl mainlenance ol Ihe improvement or other righFobway osa <br />here�o aDP�iod �or antl lurther agrees to remove same upon notice <br />Irom Ihe Ciry and 10 replece pu6lic property dame0ed Iherehy. <br />ACKNOWLEDGEMENT OF CONDITIOYS <br />� � <br />. � ;� �,� ;, <br />,, ,,,; „ <br />_____ - r <br />SIGNATUREOFAPPLICANT� �1DATE � � ' <br />CALL FOR INSPECTION <br />POST aN 259-8811 <br />JOBSITE 24 HRS. BEFORE CONSTRUCTION <br />