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eVw APPLICATION FOR PUBLiC WORK� PERMIT <br /> Typo or prinl cleady with ink <br /> � PRESS HARD•YOU ARE MAKING COPIES � - � � <br /> t l $ <br /> PERMIT NO. �_� -v ' � <br /> PUBLIC WORKS -- �� <br /> �ElVERETT,WASHINGTON `/_. p BLDG. DEPT. NO.� 1 �� <br /> pQOWNER ❑ AGENT DATE _�—�/ 82 <br /> ' ` C �f-�=--��'—G'� r/7��(�i <br /> APPLICANT/FIRM REPRESENTED _ .f �� <br /> ADDRESS p��E�E/��,► /JJAtL ��_CI1Y ��'LP� TELEPHONE.-�J �T� Z <br /> FIEREBY APPLIES FOR PERMISSION TO�NS//,� �/ �/v�� �-����L/Z �iP/(�cw� <br /> AT THE FOLLOWING LOCATIOPI ���e�-�'UG ����_�� 9 Vr��`i l` ��� ���'� S��;� <br /> Attach tive(5)ccpies of preliminary plans for aroposed work.Draw to sc�le and show the following as applicable. <br /> • Property lines and street icientity. ' Topographic change� �equiring cu!s and fills <br /> " Outline and dimensions of existing and other than normal foundation. <br /> proposed structures. ^ Un-site drainage systems when required. <br /> ` Existing and proposed utilities. * sion control ethods when required. <br /> " CeMerline of abutting right oi way. ' No a�w <br /> - Sig lu�e ol Applitanl <br /> �__ _—_'_ <br /> �UBLIG WOR P�RMI�' <br /> CONDITIONS: <br /> . . . . .� . . �1 v1" `7z:� �,�r� �i,,, a C /?, �<�f .�i r' G�:i�7�r'o //r� ` <br /> o „�-.� �i� % ,� <br /> / � <br /> . . . . ,7. . .',;iJNo . . . L /�/rtC7Cl . _Qi- . . ��._ [' {� CI� � �'� ".� Ir [1LIic_ . . . <br /> . ,�� .� f.y ` � � / J / � . . . . <br /> . . . � //.� . . . . �/fP �{U :v.��J/�uCT- O.-i �. . . . . <br /> � L. Lti�. oG.._�� . ,,., � i <br /> . . �19U3 � (,e� , e�rJa�r� ��- �,J `jGs��r�N.- _ <br /> .�, . < L1.<�l�i�/S. "] r'�,.•.�r�c! ? /.�'I 1"� r�[ Ei�,c ���. /�, C.U�. ' I)'.a ,•-: <br /> � �!// > i",Ci,, .�r �� .' � /t� „ . . . lc: / s ��, /; _ . '/'��,. . ..�� <br /> _) � <br /> 7-LC:'1 :�:'i��U <br /> �A/9C 1 NSPECT16 <br /> A . jZotKEfLY Hhs A �o�SL�o�E ���Ru S�rLL� TH� FREE �A�-�-$ u�AT� <br /> Ta �� �u����D , ,��A� The undersic�ncA ownm Lere�y agrees to hcld and seve harmless <br /> ON �� �-r 'L�r � C�� IhE Cl�y 0� EvUroli 1�010 a� 0nJ 011 Gaims IOf daTPBP9 W515, <br /> g, }Zo� pR/4�1JS l>SE $���'SP/ ���'$ e�venses.or causes o�aci ae may erise because ol instelletion <br /> gT�R m.V $OlJTt� S/QFj L��N�E TR.�TL� ana maintenance ol Iho '�ement or ot�er r9nt�o4way use <br /> �/,S �RUS/N'� CRLlS/ON herelo apDlled lor enE lu � .reos to remove saide upon nmico <br /> C. 6Uy-T��� ,UEEp,S GLEqAS(�J6 ��. ' irom Ihe Ciry and �o n '� �ub6c y.operty demBBod Ihereby. \ <br /> �i •p �' � <br /> �•1 �"i��� � ✓ ✓ �_ � � 1 �� <br /> ,�A ROVED fOR ONSTRUCTION DATE �V� � ACKNCJWf:EDGE �IJT O CONDITIONS <br /> _ __ �n ��, I, ���/ / �--- --- -- ----- . <br /> APf'ROVED %-.SCONSTRUCTED DAiE �'� �� �� SI-NATUR O APP CP.N1� DATE <br /> ' CALL FOR INSPECTION �� <br /> PE4iMl7 IS VALlD FOR 1 YEAR pOST ON 259-8811 <br /> EXPIRATION � �� �-' _ JOBSI7E p4HRS. BE'FORECONSTRUCTIO�ti I <br />