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EVERETT, WASH <br />The Undersigned% <br />'11pproved By <br />Defile Approved <br />Hereby applies for permission <br />At the following location <br />SKETCH <br />(Work to be dor <br />The undersigned owner hereby agrees to hold and save harmless the City of <br />Everett from any and all claims for damages that may arise because of the <br />installation and maintenance of the improvement hereto applied for and <br />further agrees to remove some upon notice from the City and to replace all <br />public properly darnaged thereby. <br />is NOTE <br />CHECK WITH WATER <br />DEPT. FOR V.ATCR LINE <br />LOCATIONS BEFORE EXCAVATICN <br />Inspect s Signature <br />Dale <br />, c:. <br />.,,,...�.....-.....__... -. •,.ram..,......-.,,.. <br />Variance Required <br />Yes <br />No <br />Signature of Applicant <br />it <br />Address <br />? - -; '� (. C r , <br />elephone Number <br />coCYi <br />CV <br />Date <br />$ ±C 4-IIIBb <br />Fee / / 1 <br />Dr Dlty <br />DEPT. APPROVALS <br />Engineers <br />Water. s. _ ' Lb6. 2 <br />Street _ <br />Communicalions <br />Traffic <br />Planning <br />