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<br /> everett APPLICATION FOR PUBLIC WORKS PERMIT
<br /> Type or prinl cleerly wllh ink �
<br /> PRESS HARD•YOU ARE MAI•:ING COPIES ,
<br /> PERMIT NO. �_� /� 3 �•
<br /> PUBLIC WORKS __
<br /> EVERETT,WASHINGTON '�/ BLDG. DEPT. NO._
<br /> �OWNER ❑ AGENT DATE `/3�J�v
<br /> APPLICANT/FIRM REPRESENTED �/�CL_La/ CC._L�!r-�-c�L-�'���--1�_
<br /> .L /� [�c:t�rc� 'l-7 3�
<br /> ADDRESS _��D� .�_ /��?�/ i9��,.,_,_�,!_+r�_ CITY �(L���TELEPHONE 2�—��fn
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<br /> HEREBYAPPLIES FOR PERMISSION TO CO//��1�tc f C�ti,� Y ' ��L,s� [c// t/[ /h�f/
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<br /> ATTHE FOLLOWING LOCATION � �*����l�ii[�a'—
<br /> Attach five(5)copies of preliminary plans for proposed work Draw lo 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 tha� normal foundation.
<br /> proposed structures. ' On-site drainage systems when required.
<br /> ' Existing and proposed utilities. " Erosion control methods when required.
<br /> • Centerline of abutting right oi way. ` Nort arrow ; , "
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<br /> Signeture ol Applicent
<br /> PUBLIC WORKS PERMIT
<br /> CONDITIONS:
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<br /> // �T�e undersigned owner he�eby agrees to hold anA save harmless
<br />� � � ��,' �;'•L / �'l�J�'✓i^ '��'�f,�' /�}/�������� / Ihe City ul Everett t:om nny ena au clalms lo! demeBas, cosls,
<br /> a�'�//F� /C� �-- � '.L /`./u// r,�/ `j- expenses,or causes ol acGon that mey arise because ol Inslalletion
<br /> y- �( . 7 . � �nd maintonance of !he Impmvement or othor nghPo4wey use
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<br /> �/ ) - -� /t� �(��c�i�� ��� hercto applied lor and lurther egrees lo rrmove same upon nolice
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<br /> � r���/ y-�.y y ,� ��J3N�i�„� Iwm ihe Cit antl to ropleco public proDerty demege0 thereby.
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<br /> �APPRO E R ONSTRUCTION A ACKNOWIEDGEMEN7 F.C�ON ITIONS ' '
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<br /> APP OVED AS CONSTR ED � DA � � �"���TUR 'J F-�CANT/ ��\ DA E � �,/
<br /> PERMIT iS VALID F'JR 1 YEAR pOST ON CALL FOR INSPECTION
<br /> 259-8811
<br /> EXPIRATION �' ' ' �, ' JOBSiTE 24HRS. BEFORECONSTRUCTION
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