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everett APPLICATION FOR PUBLIC WORKS PERMIT <br />� TYPe or Print cleadY wilh ink <br />PRESS HARD - YOU ARE MAKING COPIES pERM1T NO <br />PUBLIC WORKS . <br />EVERETT,WASHINGTON <br />❑ OWNER ❑ AGENT DATE . <br />APPLICANT/FIRM REPRESENTED _ <br />ADDRESS __-- _ ------- --- <br />HEREBY APPLIES FOR PERMISSION TO <br />BLDG. DEPT. NO. ___ <br />TELEPHONE — <br />AT THE FOLLOWING LOCATION - -- --�-��-- -- — --� <br />Attach five (5) copies ot 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 />' Exisling and proposed utilities. ' Erosion control methods when required. <br />' Cenlerline o( abutting right of way. ' North arrow <br />�ISLI <br />�J _ Y � -r <br />-�1 - <br />� <br />- - — <br />"--- '— - - licanl <br />-- Signaiure ol ApP <br />KS PERMIT <br />� : �� <br />;=� ;�; �:� <br />l� . L�ti -}' � J+ : � + I �-`1 <br />- _�- �♦ ' tJ- �� -t�- . ' . � . <br />-: �- - - +: �� . _ -�. ;_ <br />j �- - _ �. i -. + I ; _ _ � :- -i ,_� <br />�, -� - .� _ <br />, --.- -� �;-- r� <br />� :� � _ ._ : '_ ' ? - - _ <br />. __ . - � - -i - , - - -!- <br />� � - , , } '� � -.+ - _ - <br />._ , _. . . , � <br />_� _ ihe undersigned owner hereby aqrees to hold and save harmless <br />' _ ' tne Cily oi Everelt nom any ana au ciaims lor damages, cosis, <br />. I. . eKpenses, or c�U5o5 0l aclion �hai may afiSC 6eCause ol installa�ion <br />antl maintenance ol ihe impwvement or other riqh4obwey use <br />-i �i ��� he�eto applied lor antl lurther og�ees lo rernove same upon nolice <br />!�•- irom the Cily antl to replece puUlic propetly damagetl t�ere6y. <br />I�-...�1 _ �_�. <br />�'..':f .. <br />ATE <br />� �Z? I �2 <br />DATE <br />PERMIT IS VALID FOR 1 YEAR <br />EXPIFlATION <br />ACKNOWLEDGEMENT OF CONUfi IONS <br />__. __—_— _- <br />cicr.�nnioc�ncnPPi1CANT - . . . DATE <br />CALL FOR INSPec:t iun <br />POST ON I 259-8811 <br />JOBSITE 24 HRS. BEFORE CONSTRUCTION <br />