Laserfiche WebLink
rcn APPLICATION FOR PUBLIC WORKS PERMIT <br /> Type or print clearly with Ink <br /> PRESS HARD-YOU ARE M4KING COPIES PERMIT NO. �� <br /> PUBLIC WORKS <br /> EVERETT,WASHINGTON BLDG. DEPT. NO.__ <br /> ❑ OWNER 016ENT DATE <br /> APPLICANT/FIRM REPRESENTED <br /> ADDRESS CITY �t TELEPHONE <br /> HEREBY APPLIES FOR PERMISSION To — ��{6 40-Y1 172 <br /> r i <br /> AT THE FOLLOWING LOCATION ---- <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 methods when required. <br /> • Centerline of abutting right of way. • North arrow / <br /> Signature of Appiocam <br /> PUBLIC WORKS PERMIT <br /> CONDITIONS: <br /> fIAP A U— Pu%L_l C_ ►Zf csJ <br /> --- - The undersigned owner hereby agrees to hold and save harmless <br /> the City of Everett from any and an claims for damages, costs, <br /> expense&or causes of action that may arise because of Installation <br /> i and maintenance of the improvement or other dghl-of•way use <br /> hereto applied for and further agrees to remove same upon notice <br /> /•i' from the City and to replace public property damaged thereby. <br /> =ASCO <br /> ACKNOWLEDGEMENT OF COf1DITION8 <br /> �yCTION DATL _--I APPT DATE SIGNATURE OF APPLICANT 'TATE <br /> PERMIT IS VALID OR 1 YEAR CALL FOR INSPECTION <br /> POST ON 259.8811 <br /> j <br /> L EXPIRATION 2 - 6 j JOBSITE 24 HRS. BEFORE CONSTRUCTION <br />