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LICATION FOR PUBLIC WORKS PERMIT <br />e Type or print clearly with Ink <br />t 1 PRESS HARD - YOU ARE MAKING COPIES <br />PERMIT NO. <br />PUBLIC WORKS <br />EVERETT, WASHINGfON d <br />Q /. BLDG. DEPT. NO. // 979f� <br />❑ OWNER f�AGENT DATE -, (_L17� <br />APPLICANT/FIRM REPRESSENTED//J..�l-/_?:Y1.(Li�_�E�.,LIL.�i1-(,./.-J.-f'C.]S�J�xly.�_Ic� ♦)��1 1�1.IjdA <br />ADDRESS J 7Sl1_1rS Lam- CITY S /1 LL4L,L-__TELEPHONE=AS a - / 10 in, <br />HEREBY APPLIES FOR PERMISSION TO <br />AT THE FOLLvWING LCCATION <br />Attach five (5) copies of preliminary plans for proposed work Draw to scale and show the following as applicable: <br />• Property lines and s'-eet identity. <br />• Outline and dimen is of existing and <br />proposed structl, _s. <br />• Existing and proposed utilities. <br />• Centerline of abutting right of way. <br />t <br />• Topographic changes requiring cuts and fills <br />other than normal foundation. <br />• On -site drainage systems when required. <br />• Erosion control methods when required. <br />• North 7frow 1 <br />1 i1 <br />f~(� : �• The deisigned owner hereby agrees to hold and save-t0mless <br />/ the Ch I Everett from any and all claims lo>r rapes, costs, <br />expenses, o s c' action that me 4lIse-bei.Muse of Installation <br />and .nainterance of the p ove ent or other dght•ol-way use <br />hereto applied for and lurthar agrees to remove same upon notice -_ <br />from the City and to replace public, property damaged thereby. <br />APPROVED FOR CONSTRUCTION DATE <br />f <br />APPROVED AS CONSTRUgTEO. DATE <br />PERMIT IS VALID FOR 1'YEAR <br />ACKNOWLEDGEMENT OF CONDITIONS <br />SIGNATURE OF APPLICANT DATE <br />CALL FOR INSPECTION <br />POST ON 7SQ-RRI 1 <br />