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- _ _ <br /> � <br /> I <br /> everett APPLICATION FOR PUBLIC WORKS PERMtT <br /> � . TYPe or print clearly wit�Ink � <br /> PRESS HARD-YOU ARE MAKING COPIES pERMIT NO. �' ._".T! — <br /> PUBLIC WORKS �� <br /> � EVC-RETT,WASH�NGiON i _ BLOG DFPT. NO. — <br /> ' U �. � <br /> C7,OVr'NER ❑ ,9GENT DATE � - <br /> I�— I _ I � .. . T'--'1 <br /> APPLICANl/FIRM REPRESENTED _ — � � �� � �- - --'—�J � � --t--� �--� �� �-- — <br /> � . �� �' V - � �� _ •� �� <br /> A:JDRESS —.--.---_------- 'f ` �/ CITY i.r._ �' ,__TELEPHONE% � ' <br /> �I HEREBY APP�_IES FOR PERMISSION TO �/� ` °�� ''��` —.� � � � " P%� �__ _ _ _— — <br /> --� ——��----- - -- <br /> --- - - -- - -�- --- - <br /> � • / '! <br /> ATTHE FOLLOWING LOCATION __�_��_ ._ � . % '-` ���'" — <br /> �i <br /> Attach live(5)cc�pies ei r�redminary plans for proposad work Draw to scale and show the following as applicable: <br /> ' Property lines and street identity. ' fopographic changes requiring cuts and tills <br /> ' Ou:line and dimensions of existing and other than normal toundation. <br /> proposed structures. ' On-site drainage systems when required. <br /> ' Exi;ting and proposed utilities. " Erosion control methods when required. <br /> " Cenf2rline o( abulting right of way. ' North arrow <br /> ' -- <br /> i _,.' ' /__' <br /> � � � �Sign2lure 6�ApVlitant <br /> - PUBLIC WORKS PERMIT � ` <br /> CONDITIONS: <br /> ; _ . , . <br /> , . . <br /> � <br /> � l4=�. u�dorv�nced oHnr: hi�reby agit'es lo hr,ld snA sove harmlCsS <br /> Ihe Gly ol [veru�l vom any ano au ciaims for damages, cosls, <br /> � ez0enses,or causes ol ar.ti0n��at may arise beceuse ol in5tallalion <br /> ' � . end mainlenance ol ihe improvement or ol0er righ4obwsy use <br /> � herelo applied lor end Imther agrees to remove same upon notice <br /> � � irom the Ciry and to repiece public property damayed Uereby. <br /> i� �� � � <br /> � -� �..:---=��-�!=-F'-' <br /> AP�OV F R CONST� DATE.� ACKNOWLEDGEMENT OF CONOITIONS <br /> � � �(i`8� - --- - <br /> A ROVED AS CONS' CTED DATE SIGNATURE OF APPLI�.ANT DATE <br /> PERMIT IS VALID FOR 1 YEAR CALL FOki INSPECTION <br /> POST ON 2ti9-8811 <br /> JOBSITE �q HRS. BE.F:�RECONSTRUCTION <br /> EXPIRA7IQN ---- ---- <br />