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�' <br />_ . <br />_ . _ _ _ _ -----� <br />�°"`re pppLICATION FOR PUBLIC WQRKS PERMIT <br />TYPe or print clearly with ink �� f� <br />PRESS HARD - YOU ARE MAKING COPIEu pERMIT NO. ��" <br />PUBLIC WORKS <br />EVERETT, WASHINGTON / BLDG. DEPT. NO. �%/ 6 <br />�OWNER ❑ AGENT DATE p Z b�- / <br />APPLICANT/FIRM REPRESENTED _ �/L� I�i'H.PKts72 <br />ADDRESS � / % S/ Q� �L !/ <br />S � � CITY �=r �X�T TELEPHONE -2S �I -- GS�-� <br />HEREBY APPLIES FOR PERMISSION TO /+vIJ /6 X 20 � /-%.()l��T� 0� 1 U <br />�-�c �.cr�n�� �dous�- <br />AT THE FOLLOWING LOCATION �'J�% ��� Y�C_ s'w (y UL�L''4"Q' (�/ R <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 />�y% � �1/�!t«� <br />sie�emr of Applicent <br />PUBLIC WORKS PERMIT <br />PERMIT IS VALID <br />EXPIRATION <br />R 1 YEAR <br />The undersigned awnar hereby aBrees to hold and eave hermlees <br />the City ol Evarett trom any ena au clalms lor damaqe0. coel; <br />expenses, or ceuaes ol action thet mey arise becauee of Inatallatbn <br />antl maintenance ol the Improvemant or othar right-of•wey use <br />hereto applied lor anE further egreee to remove eame upon nollte <br />from �he Ciry and to replete Dublic property damaqaA thereDy. <br />�-(rZ_ <br />—! � \ACK LEDGEMENT O� N I ION�-- <br />// iG Z .� <br />� Sf6NATUREOFAPPLICANT DATE <br />POST ON I CALL FOR INSPECTIC`N <br />JOBSITE �59•8811 <br />24 HRS. BEFORE CONSTRUCTION <br />J <br />__� <br />