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r <br />w APPLICATION FOR PUBLIC WORKS PERMIT <br />G Type or print clearly wilt rJ <br />PRESS HARD • YOU ARE MAKING COPIES PERMIT NO. is �-z 3 <br />PUBLIC WORKS p.y <br />Ev ETT, WASHINGTON ` BLDG. DEPT. NO.JWJ.�L/ � <br />'OWNER ❑AGENT DATE /va � y _ <br />APPLICANT/FIRM <br />ADDRESS <br />ONE SS 3— HY;2— <br />HEREBY APPLIES FOR PERMISSION TO <br />AT THE FOLLOWING LOCATION &/0 ( S r� 81e S.E. <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. a 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 Applicant <br />CONDITIONS: PUBLIC WORKS PERMIT <br />/. 411 wor4 S/a/// Oc �r=r'7o1.._rr rcl �n n�Cforr�it'nCCL •••rla 411' <br />�n3Y%'wc' �ory! .�grp•rt�rr`rr� /p.+�.F .�c. r�n:/'�arrt' r <br />The undersigned owner hereby agrees to hold and save harmless <br />the City of Everett from any and an ctauma for damages, costs. <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the Improvement or other righrof-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 />R CONSTRUCTION T ACKNOWLEDGEMENT OF CONDITIONS <br />DATE SIGNATURE OF APPi ICANT DATE <br />PERMIT IS VALID FOR 1 YEAR <br />FXPIRAT10N Z227 'f j <br />POST ON I CALL FOR INSPECTION <br />259.8811 <br />JOBSITE 24 HRS. BEFORE CONSTRUCTION <br />