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r <br />e� APPLICATION FOR PUBLIC WORKS PERMIT <br />Type or print deatly wi�� ink <br />PRESS NARD - YOU ARE MAKING COPIES <br />PUBLIC WORKS P[RMIT NO. �_ ��Z o�_ <br />EVERETT, WASHINGTON <br />❑ OWNER ❑ AGENT DFTE ����P_�- BLDG. DEPT. NO. C���/J //.> <br />APPLICANT/FlRMREPRESENTED _..Qv�� _CC�� �CMS-� �YO T/U�--- <br />ADORcSS��OV � �y__�J CITY ��U/ TELEPHONE�S�/`S�S� <br />HEREBY APPLIES FOR PERMISSION TO _CC7 -5�� � � <br />�'DA_c} l_U/n.___�__�c�_r.��,si-�� � <br />y�-Q—__CIZA�� �ftn-.��'--------- <br />ATTHE FOLLOWING LOCAT�ON _S��(� _w�-K-�O�-����� ���,'i� m <br />Attach five (5) copies oi preliminary plans for proposed ✓vork. Draw to scale and show ihe following as applicable: <br />" Property lines and street identity. <br />` Outline and dimensions of existing and <br />proposed structures. <br />• Existing and proposed utilities. <br />• Centerline of abutting right o( way. <br />CONDITIONS: <br />i!• _;��_ ';. ,— <br />PERMIT IS <br />EXPIRATION <br />I `� <br />� �. <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 />' Norh arrow <br />�� � ��� • <br />SignaNrc ol ApUlican� — <br />KS PERMIT <br />�,� — <br />. :i�.�' ���i C".2.' <br />) <br />, � �� �.: c_ ��, , <br />, 'L�: <br />The unaersigned owner hereby agrees lo holil antl save hermlees <br />the C��tY o! Eve•e�t nom any ena au �Iaims br demepee, coEta, <br />evpenses, or cau3es ol aCtion Ihet may ari6e becau6e ol innta�letlon <br />antl mainlanance 41 t�e improvomenl or other rip�4obwsy uea <br />herelo ap0lietl lor and lurther agrees to remove sam� upon notice <br />Irom the City antl to replete OubllC prOperty dBmepBtl IhBreCy. <br />ACKNOWLEDGEME^NT OF CONUI710N5 <br />SfGNATUREOFA PLICANT DATE <br />1 YEAR CALL FOR INSPECTION <br />POST ON 259-8811 <br />JOBSITE 24HRS.BEFORECONSTRUCTION <br />� <br />