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everen APPLICATION FOR PUBLIC WORKS PERMIT <br />Type or print clearly wdh ink �[ <br />PRESS HARD - YOU ARE MAKING COPIES PERMIT NO. `� 1 act <br />PUBLIC WORKS y <br />EVERETT, WASHINGTON BLDG. DEPT. NO. 911100L <br />❑ OWNER AGENT DATEf�a__� <br />APPLICANT/FIRhhMREPRESENTED ._._ [�Llil`��`�'_t 1►I1. <br />ADDRESS�V - � �CITY <br />HEREBY APPLIES FOR PERMISSION TO <br />AT THE FOLLOWING LOCATION .. <br />Attach five (5) copies of preliminary plans for proposedWork <br />• Property lines and reel Identity. <br />• Outline and dimensions of existing and <br />proposed structures. <br />• Existing and proposed utilities. <br />• Centerline of abutting right of way. <br />CONDITIONS: <br />YAX <br />PUBLIC <br />1t/oCoro <br />iM�T <br />PERMIT IS VALID FOR 1 YEAR I <br />EXPIRATION <br />;3 <br />TELEPHONE <br />h p/. S F <br />to scale and show the following as applicable: <br />• Topographic changes requiring cuts and fills <br />other than normal foundation. <br />On -sit drainage systems when required. <br />• E o io control methods when r q ' e . <br />' o h a row <br />� <br />1, Jam.-- ---• <br />ons 9%w <br />NGw 1 -A)4T r�zoi�L�cJ <br />The undersigned owner hereby agrees to hold and save harmless <br />the City of Everett from any one all claims for damages, Costs, <br />expense& or causes of action that may arise because of Installation <br />end maintenance of the improvement or other right-of-way use <br />hereto applied for and further agrees to remove some upon notice <br />from Ih City and to replace public property damaged Thereby. <br />L <br />N � DGEMEN <br />SIG ATU EOF APPLICANT DATE <br />CALL FOR INSPECTION <br />POST ON 1 259.8811 <br />JOBSITE 24 HRS. BEFORE CONSTRUCTIOh <br />.-I <br />