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1 <br />j� APPLICATION FOR PUBLIC WORKS PERMIT <br />c Type at print clearly with ink <br />PRESS HARD • YOU ARF. MAKING COPIES <br />PUBLIC WORKS <br />EVERETT, WASHINGTON /I�O�� <br />❑ OWNER ❑ AGENT DATE 7 <br />APPLICANT/FIRM REPRESENTED �/,1��/G- <br />ADDRESS �L s E,�E�6� L ""A/ CITY <br />HERESY APPLIES FOR PERMISSION TO <br />AT THE FOLLOWING LOCATION 6T <br />PERMIT NO. 11 /`; � <br />BLDG. DEPT. NO. <br />��E"/r TELEPHONES L <br />Attach five (6) 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 oxisting and other than normal foundation <br />proposed structures. • On -site drainage systems when required. <br />• Existing and proposed utilities. /!,Frayinn rontrol tho s when required. <br />• Centerline of abutting right of way. ( • ND h r, ow, / <br />CONDITIONS: PUBLIC <br />ERMI <br />1. � �reer•• 3e1•� eu5c•,,re..a.�- c�e.rl=,�• IS yloY- -Iv toe c�earec� . <br />�1r cTrna�e. 11� i-� bra <br />Co•a'�Ile J/ Su+ .,u� cifaa r, vv.. •1-v 6.�`CL Gea^ <br />10Wer lo�sp J <br />i. �ny �iavr )e- oe, breakaSe. Rrbll� TO. w, occufyl% a <br />dw� -1-o aor<s1�(-"J�rr«•Ii�',on f„i,4%4 b�. refa_,�eS ,.) b..r'tic�rr..1 <br />Y, �1>r\% a-�ItX 1A f" ?,A61-4 ^.).VJ. '7VM W1,5 DNS NCiIOv, <br />b14 IS "Ib <br />,�. I/J�e! �je � � t f: c YioK 1 s .� � � a cif In 5'i �.Q �u •t I .� r;.I <br />1U Y TA Q P r for The undersigned owner hereby agrees to hold and save harmless <br />the City of Everett from any and all claims for damsgea, costs, <br />4 rt G(.I <br />expenses, Or Causes of action that may arise because CI Installation <br />`Ca flo r o j Cal • end maintenance of the improvement Or other righlol•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 />p pyEp OR C NSTRUCTION DATE <br />APPROVED AS CONSTRUCTED DATE <br />PERMIT IS VALID FOR 1 YEAR <br />EXPIRATION---- <br />ACKNO L OEM OF ONDITIONS <br />tlREO APP CANT _ DATE <br />C LL FOR INSPECTION <br />POST O 259.8811 <br />JOBSITE 24HRS.BEFORECONSTRUCTION <br />J <br />