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� �� � . <br /> Y I <br /> ' ' �""'� APPLICATION FOR PUBLIC WORKS PERMIT ; <br /> � TyPe or�rint clearly with ink p <br /> � PRESS HARD•YOU ARE MAKING COPIES pERMIT NO. _p� . I D3 I, <br /> � PUBLIC WORKS I <br /> i EVERETT,WASHINGTON .r",��_Z � — <br /> , �OWNER ❑ AGENT DATE __�// _ __ — � _ BLDG. DEPT. NO.��y�'� �I � <br /> APPLICANT/FIRM REPRESENTED /_l.�«�S _��f�ES SNL_________ _ __ � <br /> ADDRESSS' ��D S�E EVr /IC7 //'If!!L (,(/�y CITY �vc�E� TELEPHONE 3Ss-�/�z I� <br /> I HEREBY APPLIES FOR PERMISSION TO INS HC[ aT I l.(I�OF �ON�/,�(jc' �?%U�= r�I/i�� � <br /> � II <br /> I ATTHEFOLLOWINGLOCATION LC'/ 1�E/�/I[f/UE �STfI7F5 ,JjFi-�=;-zC,-t.�c �+.%.v' SG% <br /> i <br /> Attach five(5)copies o(preliminary plans(or proposed work.Draw to scale and show lhe following as applicable: <br /> � * Property lines and street identity. ' Topographic changes reGuiring 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. ' Emsion control methods when required. <br /> ; ' Centerline ot abuttinc� right of way. �'Nort� arrow � / <br /> � \ �'liiGG/ � �(¢� <br /> r <br /> � � �ignaWreolApp6can� ' <br /> PUBLIC WURKS PERMIT � <br /> CONDITIONS: <br /> � l, h'vofi- �-��,� �1r� �� � c;� e r��ust h� cor� troll e�.L on <br /> _` -N�i e l o t. ' <br /> ' �. �,:�y dan?cy e or prea kc,y� to �ub l;�. �, 0, 6�/ I <br /> � 6C'CUr !ny C1u� fo C'vnStr� c1 i or� n�us f p�e <br /> ; ; re��a�'red 1�y. bui lcic:r. <br /> � � 3• pebr�s fracr,ed in�v P��b � ,'� ;� �,L�l �-vm -t-his <br /> � ConSl�ruCfr�;r� Sif� (S �o b2 CI�PGn��( �:�p ' <br /> I The undersiqned owner heieby aprees to holtl antl save harmless � <br /> � . /y�� I� the City ol Evemtt vom uny ana au ciaims lor dameges, cos�s, � <br /> �� � e�pnnses,or canses ol action Ihnl may arise becauso ol installation � <br /> , � � � - and maintenance ol Iho �mpmvemenl or ot�or righl�obway use i <br /> , hrrclo applietl lor antl turlher agrees lo remove snme upon notice , <br /> ' Irom the Ciry antl to replace public property damaqod Iheraby. '�, <br /> ;: - ___�- � ,Sj � �d I <br /> � APPROVEDFOR�CI'NSTRt7CTl0'J DFTE . ACKNO4�'LEDGEMEN70F ONDITION� � <br /> �-�� _��c��'-at��3 � - �,`''r� !i��1� i _ ,`2 =,.? <br /> � A PROVED AS CONSTRUC7ED OATE SIGNA�E OF APPLICANT CATE �. <br /> PERMIT IS VALID FOR 1 YEAR CALL FOR INSPECTION <br /> POST ON 25g.gg� � <br /> EXPIRATION _ JOBSITE 24 HRS. BEFORECONSTRUCTION � <br />