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L <br />e APPLICATION FOR PUBLIC WORKS PERMIT <br />Type or print clearly with ink <br />PRESS HARD - YOU ARE MAKING COPIES <br />PERMIT NO. 'Z /0 C? <br />PUBLIC WORKS <br />EVERETT, WASHINGTON BLDG. DEPT. NO. <br />OWNER ❑AGENT DA1E1_Y/__ �\ <br />APPLICAN TiFIRMREP <br />/RESENTED v <br />ADDRESS _ 7 CITY TELEPHONEc.=,?S;,7- Co%3% <br />HEREBY APPLIES FOR PERMISSION TO <br />Z�f <br />AT THE FOLLOWING LOCATION— `:52q- Al'2 <br />Attach five (5) copies of preliminary plans for proposed work. Draw to 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 />�44) d �Skni:4 <br />I Signature of Applicant <br />CONDITIONS: PUBLIC WORKS PERMIT <br />The undersigned owner hereby agrees to hold and save harmless <br />the City of Everett from any and an claims for damages, costs, <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the improvement or other right-of-way use <br />hereto applied for and fer+-ar agrees to remove same upon notice <br />// G from the City and to re, ie public property damaged thereby. <br />�N ✓ Z <br />4PPR ECONSTRUCTION AT - ACKNOWLEDGEMENT OF CONDITIONS <br />n(Ale, <br />82 <br />4PPROVED AS CONSTRU TED ` DATE SIGNATURE OF APPLICANT <br />PERMIT IS VA D FOR 1 YEAR POST ON CALL FOR INSPECTION <br />259-881.1 <br />EXPIRATION JOBSITE 24 HRS. BEFORE CONSTRUCTION <br />-1 <br />_J <br />