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"'�`°" APPLICATION FOR PUBLIC WORKS PERMIT <br />� TYPe or Orin� clearlY with ink ` <br />PRESS HARD • YOU ARE MAKING COPIES pERMIT NO. ��` a J <br />PUBLIC WORKS <br />EVERETT, WASHINGTON BLDG. DEPT. NO. <br />�OWNER ❑AGENT DATE �^6__g� -- <br />APPLICANT/FIRM REPRESENTED ___R° �'r—^ �—_C �� o U N- ___ <br />ADDRESS 3�3�•5�� 5�' CITY �=yO��'� TELEPHONE a5�'457.5 <br />HEREBY APPLIES FOR PERMISSION TO ��-�� �-'�'rE'Ti'`'1T ����-`�~���'�� <br />ATTHE FOLLOWING LOCATION 3�3 "5-'� Tfd �T <br />Attach five (5) copies of preliminary p�ans for proposed work. Draw to scale and show the following as applicable: <br />* Property lines and street identity. <br />* Outline and dimensions of existing arid <br />proposed structures. <br />• Existing and proposed utilities. <br />" Centerline of abutting right of way. <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 />* North arrow <br />.,c �,•..�' �• ..�t,�-o-/ <br />Signature oi App�icant <br />IT <br />1 , � ' ; � -', _ ' <br />t � ` � <br />F � � � . , i <br />, <br />�� F ' ? . <br />� '- -� , � <br />� �.__ , } }._ <br />, , , <br />_� � b 1 �...::... � ..�. <br />1..!.. , .'..• <br />i i <br />PERMIT IS VALID FOR 1 YEAR <br />EXPIRATION <br />� <br />I <br />:i � � . .; . _.. . :... <br />, � <br />,;-_�� �--� � : ` <br />, <br />, � e. <br />- E � ' <br />_' ' � . :.." I i . , ' <br />- i i � � , � ..i <br />� � i 1 _ <br />_ 1. � . . � �.�� 1 ��L . <br />. ' �� ;� __.L_ <br />, <br />, T , � <br />.� <br />� , <br />..;: "��r '' <br />: ! _. <br />�� The undersigned owner hereby agrees to hold and save harmlesa <br />the City ot Everett trom eny ana au ciaims lor damapa4 wata <br />expe�ses. or tauses of action that may afiee becauae of inatellatlon <br />and mainte�ance of ihe improvement or other rip�Fol-wey uee <br />hereto apD�ied for and lurther egrees to remove same upon nolke <br />� from llie City and 'o replace public property damaqed Ihereby. <br />� L <br />ACKt�OWLEDGEMENT OF CONDITIONS <br />z� ti Jt� �j' �M�+— _ <br />SIGNATURE OF APPLICANT DATE <br />CALL FOR INSPECTION <br />POST ON 259•8811 <br />JOBSITE 24HRS.BEFORECONSTRUCTION <br />_� <br />� <br />�� <br />