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�everett APPLICATION FOR PUBLIC WORKS PERMIT <br />TYVa ar Print claerly wil� ink <br />PRESS HARD - YOU ARE MAKING COPIES pERMIT NO. $°� 7 <br />PUBLIC WORKS <br />EVERETf, WASHINGTON BLDG. DEPT. NO. a OI.3� <br />❑ OWNER �AGENT DATE I— I I— Si � <br />APPLICANT/FIRM REPRESENTED �R2LE-y C' LH �'SSoL_� <br />cJ <br />ADDRESS� l00Z /O��' S7 CITY SNDNo�,�S/•� TELEPHONE��-3%7S <br />• „ , <br />HEREBY APPLIES FOR PERMISSION TO �S C �C�S i/NG.___�� /✓BW A L, C <br />ATTHE FOLLOWING LOCATION .�Z-3Z �oc��FE���E� Ev�.2�7f <br />Attach five (5) copies of preliminary plans for proposed work. Draw to scale and ;how the following as applicable: <br />` Property lines and street identity. * Topographic changes requiring cuts and fills <br />* Outline and dlmensions of existing and other than normal founda:�on. <br />proposed structures. * On-site drainage systems when required. <br />' Existing and proposed utilities. ` Erosion control methods when required. <br />`Centerline of abuttinc� right of way. • Ncrth arrow <br />�__ �, _ <br />�� � <br />Signature ol Applicant <br />PUBLIC WORKS PERMIT <br />CONDITIONS: <br />.. _.....� ... ... l \i <br />........... ....i ... . <br />!, . � ' , 1 � I • • � , <br />� �_� ___ __. � ._ . . �:�- <br />� . . ..: �; <br />: :_: : .� : . . , nl � <br />_����_ :: .; �:���. <br />� ..-,� . <br />' :-:f_ : : : : : _ ' �! �" - <br />_... . �. <br />::: / <br />..,_�-�. . _ _ . . . . r. . . . . . . . . . . . . . <br />. . . . . . . . . . / . <br />� // ///�— <br />�F � �/L„_ ��L� ` .. -�•/���L� <br />�ROVED FOR C NSTRUCTION CATE <br />APPROVED AS CONSTRUCTED )ATE <br />PERMIT IS VALID FOR 1 YEAR <br />EXF'I RATION <br />The undersignetl owner hereby agrees to holtl and save harmless <br />ihe Gily ol Everell Imm any ana an cia'ms for demapes, cos�s, <br />expenses, or causes of action thal may arise because ol installalion <br />and maintenance ot thu improvemenl or othe� righ4ol-way use <br />hereto applied lor and lurther egrees to remova same upon nolico <br />Irom Ihe City and lo replace public property demxged Ihereby. <br />' <br />ACKNOWLEiIGEMENT OF CONDITIONS <br />��� <br />i� � SIGNATUREOFAPPLICANT DATE <br />CALL FOR INSPECTION <br />PiIST ON 259•8811 <br />JOBSITE 24HRS.BEFORECONSYRUCTION <br />m <br />