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� <br />r <br />e"e`e" AhPLI��AT'ION FOR PUBLIC WORK <br />� TYP2 or Print cleadY wi�h ink <br />PRESS HARD • YOU ARE MAKING GOPIES <br />PUBLIC WORKS <br />E�V/�q ETf, WASHINGTON .� �%� 7 <br />pYOWNER ❑AGENT Df�TE —���'� �-/- �L�=/ <br />APPLICANT/FIRM REPRESENTED _/_`.�'�"��� -`�--'������ ----�----�- <br />� ��t�(j �i � �� �. ���, <br />ADDRESS _ L s(7----- _ _ <br />— � . i <br />HEREBY APPLIES FOR PERMISSION TO ./n <br />AT THE FOLLOWING LOCATIUK _\_���� ' �� � ' �'— <br />Altach five (5) copies ot preliminary plans for proposed work. Draw to scale <br />' Property lines and street identity. <br />` Outline and dimensions o( existing and <br />proposed structures. <br />• Existing and proposed utilities. <br />' Centerline of abutting right of way. <br />naPROVED AS CONSTRUCTED DATE <br />PERMIT IS VALID FOR 1 YEAR <br />EXPIRATION <br />� <br />r ; <br />S PERr�f <br />PERMIT NO. �� ( � � <br />BLDG. DEPT. NO.�a S �y <br />TELEPHONE �S � '�'� � <br />the tollowing as applicable: <br />' Topo ic changes requiring cuts and fills <br />er than normal foundation. <br />* n-site drainage systems when required. <br />• Erosion control methods when required. <br />• North arro � <br />il�/Q � `tE� L-, �--�7" t"' <br />Signature ot Ap0lican <br />KS PERMIT <br />�_,� - —; t <br />,_ a � <br />�-� o � ; - -��' �-S'd! <br />-� -+ <br />�-� -� 4 �_ . <br />._- --• �J -• - ���_. <br />--' '- r �'�t-t~ 7_ 1_-1-� �t <br />� The undersigned owner hereby agrees to nold and seva harmless <br />�. the City oi Everelt Irom any ana en claims for dameBea ��s�e� <br />e�penses, or cxusos ol action that may arise becaune ol instellallon <br />end main�BnBnGe ol �hE improv8meni or Other fiOh��Of�wey u9e <br />-F hewto apPlied lor end lurther agrees to remove same upon notice <br />-i from Ihe Ciry and ta repince public pmperty damaped I�ereby. <br />POST ON <br />JOBSITE <br />CALL FOR INSPECTIOM <br />259-8811 <br />24 HRS. BEFORE CONSTRUCTION <br />� <br />