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evercn APPLICATION FOR PUBLIC WORKS PERMIT <br />Type or print clearly with ink <br />PRESS HARD - YOU ARE MAKING COPIES PERMIT NO. Z Id- 3 <br />PUBLIC WORKS <br />EVERETT,WASHINGTON 7 BLDG.DEPT.NO. <br />❑ OWNER ❑ AGENT DATE!— 3 - nn <br />NI\ nnA <br />APPLICANT/FIRM REPRESENTED <br />ADDRESS <br />HEREBY APPLIES FOR PERMISSION TO <br />JJ/l.f .0 i/i . /JS -Y//Pf / ✓I 5 `I r <br />AT THE FOLLOWING LOCATION <br />i^ - <br />TELEPHONE <br />3 J r!�Fl S /. - <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. <br />• Outline and dimensions of existing and <br />proposed b:-uctures. <br />• Existing and proposed utilities. <br />• Centerline of abutting right of way. <br />CONDITIONS: <br />LI <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 />�7Jt�izl f.�.... <br />Signature of Applicant <br />IKS PERMIT <br />II ._ <br />VI 5 <br />3c <br />J L rtt_i <br />tj <br />.261 <br />i l l <br />The undersigned owner hereby agrees to hold and save narmless <br />t:-n City of Everett from any and all claims for damsges, costs, <br />expenses, or causes of action that may Prise because of Installation <br />and maintenance of the improvement or other tight -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 />DVED FO CONSTRUCTION DATE ACKNOWLEDGEMENT OF ONDITIO <br />I 1 \/ ��-(' l �Kl/1 /V�r ` V �l.i_V-'i�`�t-• 4-�1�.t eTF -. <br />PERMIT IS VALID R 1 Y CALL FOR INSPECTION <br />POST ON 259-8811 <br />EXPIRATION— -- <br />JOBSITE 24 HRS. BEFORE CONSTRUCTION <br />Fl <br />