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�J <br /> � <br /> � <br /> everett APPLICATIDN �OR PUB �LIC WORKS PERMIT <br /> � TYPe ar�rint cleodY with ink , � <br /> PRESS HARD-YOU ARE MAKING COPIES f''1 <br /> PERMIT NO. U�`- �— <br /> PUBLIC WORKS q� <br /> EVERETT, WASrIIIVGTON � ,/ BLDG. DEPT. NO. `J�/���� � •-. <br /> ❑ OWNER CA�AGENT DATE :1.�_' ��,-`��- _ _ � <br /> _�f_,. _ _ <br /> APPLICANT/FIRM REPRESENTED �f- �-y.�_ t=k!�c�+--:1 <br /> � �-- <br /> ADDRESS _?'��_��.�%��!���� CITY r.s� TELEPHONE�S�-�3rP� <br /> HEREBY APPLIES FOR PERMISSION TO _ `�/SG^ !_�l_, r�n�i �r�'y ��� y_ <br /> I — - — ---- - <br /> I �/' ' .-'_;_ ,�J <br /> I' ATTHE FOLLOWING LOCATION _ .�✓'�� n i' �r2:'��-—.f"�lL.:' <br /> --�-- - --�---- <br /> Attach five(5) copies of preiiminary 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 limensions of existing and other than normal foundation. <br /> i proposed structures. * On-site drainage systems when required. � <br /> * Existing and proposed utilities. * Erosion control methods when required. <br /> I� * Centerline of abutting right c` way. ` North arrow , <br /> I% �� <br /> j ---` _.t�l� �<' ''_-��r�.,l s _ <br />` �- Signalure ol Applicant <br /> I PUBLIC WORKS PERMIT <br /> � <br />�I CONDITIONS: <br /> C'.'-.: i� ', - i; '�._ i� �. _ ��,C' ; � <�= _ <br />'I <br />( � <br />��� <br /> I' <br />'� ; <br />� . <br />!. , � � - � The undersignetl owner hereby agrees lo hold and save harmless <br /> the City ol Everett Iwm any antl all claims lor damages, cosis, <br /> Ie+penses.or causes ol aclion ihat may aiise because oi installation <br />� and mainlenance of ihe improvement or othar righPobwey use <br /> 1 herelu applied for and lurt�er agrees lo remove same upon nolice <br />� , Irom the City and to replar.e puUlic property damagetl I�ereby. <br />' i ! � ' � � <br /> I! '�,�� .. , �Z ,/ :,' J . � - "���'� /�•'� � _ <br /> APP OVED FOREONS UCTIpN DA E ACKNOWLEDGEMENT OF CONDITIONS , <br />; ������� 0� �:. � � ; ^ <br /> < � n' _-' --'�-v-� <br />� AP ROVED S CON UCTED D TE � SIGNATUHE 9f APPLICANT DATE <br /> PERMIT IS VA��ID FOR 1 YEAR pOST ON CALL FOR IPISPECTION <br />� 3 �'�c ;�°�'-- JOBSITE �59•8811 <br /> I EXPfHRTIUN 24 HRS. BEFORE CONSTRUCTiaN <br /> � <br /> - - - -- - � � — � <br />