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<br /> � everctt APPLICATION FOR PUSLIIC �WORKS PERMlT ��
<br /> �`� Type or prinl clearly wil�ink
<br /> PRESS HARD•YOU ARE MAKING COPIES pERMIT MO. O I eZ �'1 <j
<br /> , PUBLIC WORKS
<br /> EVERETT,WASHINGTON 1
<br /> /O a� k � BLDG. DEPT. NO.
<br /> �OWNER ❑ AGENf DATE _._
<br /> APPLICANT/FIRMRC-PRESENTEO ��oF.cr�{ l� � _ . ,_j-_:_,r
<br /> ' ADDRESS - __ �,����•' CITY ��- �� � �_ TELEPHONE '�,���`-`-�� '�-'�'
<br /> HEREBY APPLIES FOR PEf MISSION TO F�/ ofJ� /o x_ � S U Cv . �!-1� ,,,
<br /> �I"�.��� �n� .
<br /> AT THE FOLLOWING LOCATION l-`�'�� �^��� S�`' � `�"��• � St _
<br /> Attach five(5)copies of preliminary plans for proposed work.Draw to scale and show the following as applicable:
<br /> ' Property lines and street identity. ` Topographic changes requiring cuts and fills
<br /> • Outline and dimensions of existing and other than normal foundation.
<br /> proposed structures. ' On-site drainage systems when required.
<br /> ' Existino and proposed utilities. ` Erosion contrcl methods when required.
<br /> ' Centerline of abutting right of way. ' North arrow
<br /> _1``__�.
<br /> Signature ol Applicant
<br /> PUBLIC WORKS PERMIT
<br /> CONDITIONS:
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<br /> ; , , . ���.,. � yt) .�J Ifls �411An CIP��y . . . .
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<br /> I � The untlersigned owner he�eby agrees to �old and save �ermlass �
<br /> �I Iho Ci1y ol Evemtl trom any nna an ciaims lor tlameges, cosls, '
<br /> e.r'�ses.or causes ol action thal may nrise�ecause ol installation
<br /> i , . . . . an0 maintonance ol Ihe improvemenl or other ripht-obwey use �,
<br /> i ! ' . hereto applietl lor and lurther agrees to remove same upon notice �
<br /> i ' . Irom ihe City an0 to replace public proPPrty damaged Ihereby. �
<br /> . �.�
<br /> , ��.r�:� r'� ,, ,.. .._.__ _ l-_: ,, ,`/
<br /> , APPR F C STRUCTION ' DATE ACKNOWLEDGEMENT OF CONDITIONS . __
<br /> A -DAS ON TR TED D TE�� S!GNATUREOFAPPLICANT � —�DATE
<br /> PERMIT IS VAL FOR 1 YEAE; puST ON CALL FOR INSPECTION
<br /> 259•8811
<br /> i.
<br /> EXPIRATION- JOBSITE 24HRS. BEFORErONSTRUCTIQN �_�
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