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EVERETT, WASH. <br />The Undersigned (/ 0 /Y A/ �J` <br />T <br />Ip o:ed By <br />_C? IR.(o9 _ <br />Date Approved <br />Hereby applies for permission <br />At the following <br />SKETCH <br />(Work to be <br />RO <br />�� PoRTrw <br />c At I. Uy-V <br />COrRS SECT/Oil) <br />The undersigned owner hereby agrees to hold and save harmless the City of <br />Everett from any and all claims for damages that may arise because of the <br />installation and maintenance of the improvement hereto applied for and <br />further agrees to remove some upon notice from the City and to replace all <br />public property damaged thereby. <br />3: '7�1' �� t ' <br />Inspectorvt igna�5 lure <br />Ell <br />Dal <br />Varia:.,e Required <br />Yes....._................ <br />No... ...................... <br />Signature of Applicant <br />Address <br />� rr <br />Telephone Number <br />Date <br />DEPT. APPROVALS <br />Engineer <br />Water <br />Street <br />i <br />Communicalions ,L1 .ioil <br />r- <br />Traffic <br />Planning <br />(a <br />