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<br /> �e°e`�" APPLII���TI�ON FOR PUBLIC W�RKS PERMIT
<br /> Type or print Cleady wilh ink
<br /> I� PRESS HARD-YOU ARE MAKING COPIES pERMIT NO. �� ,�
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<br /> PU6t.�C WORKS �� �
<br /> ' EVERETf,WASHINCTON �� �_ BLDG. DEPT. NO.p�:� ,� U ��� "'
<br /> �OWNEH ❑ ACENT PATE `�'_ �`"__�L"� / _ '
<br /> APPUCANT/FIRM REPRESENTED .;_/�L�l S—! LV/j^E�__-�'��-- - _ . . _—
<br /> ADDRESS ��6 �, C� L 1/e�,','T /j�/�LL LVA� GTY � ✓E-��i/ _TELEPHONE-� S yyy —
<br /> HEREBYAPPLIES FOR PERMISSION TO �/VS%ACL aS GI��GLC ID�L�',PF�_r" r�-)Q/(/�LU�Q.,
<br /> ATTHE FOLLOWING LOC4ilON 4-�'f_�zo /�c/.�A�E/UE ��'/'�j��S - 6�5 �Pr.��'��� �Vav -%t�i��
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<br /> Attach five(5)r,opies uf praliminary olans for proposed work. Draw to scale and show the following as applicable:
<br /> " Property lines and sireel identity. ' Topographic changes requiring cuts �rd 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. ` �rosiorr ontrol methods when require '.
<br /> ' Centerline of abutting righl of way. �'"North ar o ` � �
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<br /> S�qnatihe oi AnP'������
<br /> PUBLIC WORKS PERMIT
<br /> CONDITIONS:
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<br /> � �� � Thi, und^rslgned owner heicby agrecs to I�oid ana suve harmless
<br /> � ' the Cily ol Crnrelt Irom any antl 3u ctaims lo• tlamaBes, co5�s.
<br /> , . eMpvnses,or ceuses el action that may a�ise baceuse ot:�mlalla�io.i
<br /> � . .. . . . - and mnintenance of Ihe i�naroveme�t or ollier nphLil-way usr.
<br /> . . . . . . �erc�0 applietl lor and IuMer egrees to rcmovr same �pon noti� �
<br /> � Lom �he City anA to replace public property uam+�_.^o tierel
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<br /> ,�AP V D FOR CONSTRUCTION DATE , � AGKNOWLED�EMENT OF CONDITIONS ,
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<br /> � qHFA��(}AgGOtdS7AkJ6TE.Q.�ATE SIGJJAiUREOFAPP�ICANT DATF
<br /> P[RMIT I� VALtD FOR 1 YEAR pOST ON CALL F�OR INSPECYION
<br /> 259-8811
<br /> EXPIRATION �� � � k"� .1nBSITE 24HF�S. BEFORECONSTRUCTiON
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