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�"'°`"` APPLICATION FOR PUBLIC WORKS PERMIT <br />TYPe or Print ClearlY wilh ink <br />PRESS HARD - YOU ARE MAKING COPIES got � 6i <br />PUBLIC WORKS PERMIT NO. <br />EVERETf, WASHINGTON BLDG. DEPT. NO.�a D�0 D <br />�IOWNER ❑ AGENT DATE �'_.'_LI —�c�i__ <br />/ �j� � <br />APPUCANT/FIRM R�PRESENTED G� . _ �Z�tFi�LG <br />-� -� --�ze--- �--- <br />ADDRESS _1.. �.� J��j.�,�_�(t r.Q CITY n�Y TELEPHONE�'S�S � �9 <br />L n . <br />HEREBY APPLIES FOR PERMISSION TO <br />ATTHE FOLLOWING LOCATION �-3� <br />Attach five (5) copies of preliminary plans for proposed work. Draw t6 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 />• Existing and proposed utilities. • Erosion control methods when required. <br />' Centerline of abutting right of way. • North arrow <br />—�rTRs�_ ' -, ,ca..�_ <br />sign ure o A o�icanl <br />coNomoNs: PUBLIC WORKS PERMIT <br />�.., �, <br />�; . , <br />�_l�� ` j <br />�/��%� / 1't�' �� ��c:�-�' :-1J�.�� <br />The un0ersignetl owner �ereby agrees to �oIC and save �armlese <br />Ine Cily ol Everelt irom any ana au cieims lor damepea, wsta. <br />espenses, or causes ol ection thel may arise beceuee of Inal�llatlon <br />end maintenance ol Ine improvement or other riq�t-o1•way uee <br />he�elo applied for antl Iurther agreea to remove seme upon notice <br />from I�e City antl b replace public property tlamepetl thereby. <br />unie ACKNOWLEDGEMENTOFCONDITIONS <br />��' — z, .`-.._�, �/� l� ' %.�1 � i.�+, j � � `_�J� <br />DATE SIGNATUREOFAPPL- ICAN7!`� DATE / ` <br />PERMIT IS VALID FOR 1 YEAR <br />EXPIRATION <br />POST ON CALL FOR INSPECTION <br />JOBSITE 259•8811 <br />24 HRS. BEFORE CONSTRUCTION <br />� <br />