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� <br /> �everett APPLICATION FOR PU�BLIC WORKS PERMIT <br /> TYPe or Print clearly with ink / <br /> PRESS HARD-YOU ARE MAKING CCPIES S��/?y I <br /> PUBLIC WORKS PEf7MiT NO. ___ <br /> EVERETf,WASHINGTON BLDG. DEPT. NO. ��y�0�I�y.� <br /> ❑ OWNER �GENT DATE - S'�S/ �J �— _ --- <br /> APPLICANT/FIRM REPNESENTED �I-('_.I . _ I G/ 1� Y{ y <br /> I 7 n / / — <br /> ADDRESS �_5 3_Z_.J�4� w � •_ fl i�c -i /� �7. CITY _r'dc t1L_7ELEPHON[ �_�-3�- �/G•S��S <br /> HEREBY APPLIES FOR PERMISSfON TO /�S--f -G�s 5 �ic ��y. v—� �.c�,�q <br /> �- 7 <br /> AT THE FOLLOWING LOCATION .__� � � � -C .:..w � ��,. ; � -. __ _ <br /> f- L —r <br /> Attach five j5)copies ot prelir.iin: ry plans(or proposed work. Draw to scale and show the following as applicable: <br /> ` Property lines and street identity. ' Topographic changes requiring cuts and tills <br /> ' Ouliine and dimensions of existing and other than r�rmal toundation. ' <br /> proposed struciures. ' On-site drairage systems when required. <br /> ' Existing and proposed utilities. ` Erosion control methods when required. <br /> • Centerline of abutting right of way. • North arrow , <br /> -- -�y���-`_� <br /> Signature of ApP�itanl <br /> coNoirioNs: PUBLIC WORKS PERMIT <br /> / o�, /� <br /> �� � <br /> d � �` �c <br /> The •.ntlersignetl owner here�y agrees to hold antl save harmless <br /> the City ol Everetl trom any ano au cieims lor damapas, conts, <br /> expenses,or causes of action Ihat may arise because ol inelnllnt�on <br /> entl maintenance ol t�e impmvemenl or c!her ri0hl�ohwey uae <br /> herelo appi�ed lor antl lurther eBrees lo remove eame upon not7ce <br /> _��� Irom Ihe Cily and lo replace public property tlemeBed �hereby. <br /> ' "l.�-l� _�---�'C 7'�- <br /> .. O ED FOR CONSTRUCTION ACKNOWLEDGEMENT OF CONDITIONS <br /> � —�-�Z ,�i�ll������,�£�� �s'/li -�.� <br /> APPROV[D AS CONS CTEO DATE SIONATURE OF APPLICANT DATE <br /> PERMIT IS VALID FOR 1 YEAR CALL FOR INSPECTION <br /> POST ON 259-8811 <br /> i <br /> EXPIF2ATION JOBSITE 2qHRS. BEFORECONSTRUC710N <br />