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1 <br /> averen p��pLICATION �OR PUBLIC WORKS PERMIT <br />� e <br /> Type ur print clea�ly wilh ink � <br /> PRESS HARD•YOU ARE MAKING COPIES pERMIT NO. �^� '�I <br /> PUBLIC WORKS - <br /> EVERETT,WASHINGTON BLDG. DEPT. NO.__ � <br /> �� - I � - � '- <br />�I� �7 OWNER ❑ AGENT OATE .__ _ —__—_- / <br /> , / , / _ . , <br /> APPLICANT/FIRM REPRESENTED L�_�''C.��-�'-_.. :--`-='-�`"�`--�/�!'+--�---.- . . - --- <br /> ��.�.; -� ��_,;.�.,7c' � ;''_`'c: �rrf' � �. . _CITY ��'tP"�,�TELEPHONE .SS S • S �=`� % <br /> ADDRESS �— -- — — <br /> HEREBY APPLIES FOR PERMISSION TO .—,'��"����' -:t�"��`�°- '1�� �-`i-=L`=' '✓r "� <br /> --—- ---- r_ 7 '7; i s � I .� J 7 � .,. �, .`, ` � � .. <br /> ATTHE FOLLOWING LOCATION �_�?�;—_1J?��1_{�:�;�-=-1-��a-=<"�--=�----'-�-� '' <br /> i,:� / � <br /> Attach five(5)copies o( preliminary plans for proposed work.Draw to scale and show the fotlowing as applicable: <br /> � Property lines and slreet identity. ' Topographic changes requiring cuts and tills <br /> ' Outline anc: �imensions of existing and other ihan nurmal foundation. <br /> proposed stii:ctures. " On•site drainage systems when required. <br /> ' Existing an� prc��osed utiiities. ' Erosion control methods when required. <br /> ' Cenlerline of a`��ittir� right o( way. ' North arrow <br /> . ;:��c ./ ' �.�_�-�=�L-- . <br /> --- - — Si9naNre ot ApPlicanl <br /> CONDITIO�'S: <br /> PUBLIC WORKS PERMIT <br /> � <br /> The unticrsigned owner nereby aBrG•s to hold antl save harmlass <br /> Ine Ciry ol Evoretl Irom nny entl mi claims lor tlamo0e5, cosls, <br /> expenses,or wuses ol nction that may arlsa bernuse ol Instellalion <br /> and maintnnance of Ihe imDmvament or olhor ri0ht-ol�way ueo <br /> � . � �� ., hereto oOP�ietl lor and lurther a9ree5 to removo semu upun notice <br /> ` ._ ___� � ' Imm the City anE to replece public propotly dumaged there0y. <br /> - , . � /: r %�- - __ <br /> ; ,� � - �-::; �� -- <br /> IAPP�i UVP�� F C N TRU TI N DATE ACKNOWLEDGEMEN'f OF CONDITIONS <br /> // �— � <br /> r � i/,��- . � <br /> �`— �j: / � _�� ''-- .� �. s ./.�-r.-�� <br /> APFAOVFDAS ONSTRU D� DATE �SIC'N4TUFEOFAPPLICANT DhTE <br /> PERMIT IS VALID FOR 1 YEAR CALL FOR INSPECTION <br /> POST ON 25g-g811 <br /> EXPlRA710N JOBSITE 24 HRS. BEFORECnNSTRUCTION <br /> �� <br />