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� <br /> � <br /> 7 <br /> everen APPLICATION FOR E�U�LIC lAft➢E�KS PERMIT � <br /> � TYPe or prir.l clearlY with ink � '� <br /> PRESS HARD-YOU ARE MAKING COPIES e.�� � <br /> PERMIT NO. �-��- <br /> PUBLIC WORKS 1 <br /> EVERETT, WASHING7pN BLDG DEPT. id0�6��' 1 <br /> �,.OWNER ❑ AGEI�T DATE _.3_`��-_-�..^___ <br /> APPLICANT/FIRM REPRESENTED ��d���z a../^Jbiv______c_t�yeclYai(/._______ <br /> ADDRESS . � 3 -�� iO�J 'y �✓/_"_ CITY /3fi��k-�v3 TELEPHONE � '� 3 •�5�'Y <br /> i <br /> HEREBY APPLIES FOR PERMISSION TO /iv s —� �c= .7 :'��i��K /!,/C�_ Si/I�t.� ' <br /> rls_t:.�i.. .�c__� 13_:.r r'in[�-= s.c.�--s '3 i 4. 3 :L. !3 : [,�.IG 3.�_ <br /> RiV�t..'L Ail�c.iL /9��Su.�:N �i./K•�r <br /> ATTHE FOLLOI+�!VG LOCATION � �' ��'/;Nd 2 i_3''H C rutNn_ C>f4:�iva•: <br /> �3 I I ? I `� �= ",�. -�--� <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 /> * Outiine and dimensions of existing and other than normal foundation. <br /> I proposed structures. * On-s' e ainage systems when required. <br /> * Existing and proposed utilities. * Ero ion ntrol metho n required. <br />� * Centerline of ab�tting right cf way. ' N " h ar ow <br /> --�/� / - v� --- <br /> Si9nature ol APplicant <br />� PUBUC WORKS PERMIT r <br /> CONDITIONS: <br />� � . � . � �. _ <br /> I�. . . : . . . � � : . . . <br /> .-• - - . __t_-.._._. ... . . _ . _ __ . _ <br />� . . . . � . . . j : . . . . . . . . . . <br />! . . . . � . . . i . . . . . . . � . . . . . <br />� . . . . . . . : I . . . . . . . � . .. . , . . <br />� . .'__ 1.._ . .. , _ .� � � .: , . . _. <br /> i � <br />, <br /> . <br /> i ._�.�__—. r---_.�_—�--- . .__ � <br />�� 7he unUersigned ovmer her�by ugrces to hold antl save hormless <br /> . , . �he Ciry cl Evere�� vom any ana an ciaims for damages, cosls, <br />, . . expenses.or causos ol action ihal may arise bowuse ot installalion <br /> - . . . � � � and mainlenance of ihe im0�ovement or other righ��o4way use <br /> � � - � - � herelo applied tor and Iurlher,prees to remove same upon noiia: <br /> li � � � � (rom lhg-.ity and to replace public pwperty damaped ihcreby. <br />( �j.� <br />� '� � <br /> / n ' ��� �' L G� , ' <br /> RPP O CO UCTI N D F� '; A K OWL �/E T QNDITIONS <br /> �i (� i <br />, � v y���' �''_� , � ` ��'J?'�I;�� L- � �� ` ���j E;' � _ <br /> APPROVED AS CONSTFt�J TED ' ATE SI A R OFAPPLICANT DATE <br /> PERMIT IS VALID FOR 1 YEAR pOS7 ON CALL FOR INSPEC710IV <br /> f�� � JOBSITE 259-8811 <br /> �3:�IFiATION ' � ' � �--- 246�9RS. BEFORECONSTRUCTIO�! <br />