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everett APPLICATION FOR PUBLIC WORKS PERMIT <br />Type or print clearly with ink <br />PRESS HARD - YOU ARE MAKING COPIES P°RMIT NO. <br />PUBLIC WORKS <br />EVERETT, WASHINGTON <br />BLDG. DEPT. NO. <br />,*K OWNER ❑ AGENT DATE <br />APPLICANT/FIRM REPRESENTEDtnscs�" <br />_ <br />! `�> ��r <br />' <br />_ CITY <br />/��ACDRESS <br />TELEPHONE ��:7 `/ <br />HEREBY APPLIES FOR PERMISSION TO <br />_�we <br />— r-tyf'way <br />J <br />AT THE FOLLOWING LOCATION 47C2V 33 < <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 ethods when required. <br />• Centerline of abutting right of way. ' North arrow <br />le <br />Signature of Xprillil <br />CONDITIONS: PUBLIC WORKS PERMIT <br />PERMIT IS <br />EXPIRATION <br />The undersigned owner hereby agrees to hold and save harmless <br />the City of Everett from any and all 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 further agrees to remove same upon notice <br />from the City and to replace public property damaged thereby. <br />N DATE G—•._. ACKNOWLEDGEMENT OFCONDI1 5 <br />` DATE �_ SIGNATURE OF APPLICANT DATE <br />IR 1 YEAR CALL FOR INSPECTION <br />POST ON 1 259-8811 <br />JOBSITE 24 HRS. BEFORE CONSTRUCTION <br />