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eVw APPLICATION FOR PUBLIC WORKS PERMIT <br />� Type or pnnt cleetly wil� Ink <br />PRESS HAqD - YOU ARE MAKING COPIES pERMIT NO. �� <br />PUBLIC WORKS <br />EVERETT, WASHINGTON BLDG. DEPT. NO. <br />❑ OWNER C9'AGENT DATE r� S/ _'7_,�� <br />��� ��� l�- . —i./ <br />APPLICANT/FIRM REPRESENTED Q�J_�-_—" /' : ' � _ ' 1 _ <br />L Y � �• <br />ADDiiESS ��� ��- �� ��U�- �I, b� CITY �� S�r��`'"� TELEPHONE �5��-�%a�" <br />HEREBY APPLIES FOR PERMISSION TO � K�ST �"� C- � ���L�L (%%�l ���«/�"� <br />ATTHE FOLLOWING LOCATION �� i� �'%E-'-� ✓✓p� _ <br />Attach five (5) copies of preliminary plans tor proposed work. Draw to scale and sho.v 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 />` Existing and proposed utilities. ' Erosion control methods when required. <br />' Centerline of abutting ric�ht of way. ' North arrow <br />����✓✓t j , '� ,�1 <br />SignaWreolApO�cent <br />PUBLIC WORKS PERMIT <br />CONDITIONS: <br />; �v <br />I <br />�� <br />�� .;_ : : <br />; .� — ; ! !- _-. �. _ . <br />� <br />PERMIT IS VALI� FOFY1 YEAR <br />,i ;- � (.�>� <br />EXPIRATION <br />�-( /�'/l.c� <br />i <br />The undersignetl owncn c�reby agrO to �old and save haimless � <br />Ihe Cily ol Everett Iwm xny ana au clelms lor tlameBes, Costs, I <br />ezpenses, or causes ol aclion Ihol may ariso bacause o� inslallation <br />� and maintenance ol the improvemenl or othe. right-af�way use ' <br />hereto applietl lor and luriher agrees 10 remove same upon notica � <br />Iwm the City antl to ieplace public properly dama8ed ihereby. <br />z /� �— ACKNOWLEDG/EMENT OF CdNDITIONS <br />�� . �(. � .��-�.%C�, �-�/ ��"�� � <br />5 GNATURE OFAPPLICANT � DA?E � <br />CALI_ FOR INSPECTION <br />POST ON 259-8811 <br />JOBSITE 24HRS.BEFORECONSTRUCTION <br />