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r <br />w" IQPPLICATION FOR PUBLIC WORKS PERMIT <br />Typa or prinl cleedy wllh ink <br />�� PRESS HARD - YOU ARE MAKING COPIES $� <br />PUBLIC WORKS PERMIT NO. _ __ __7 � _ <br />EVERETf, WASHINGTON {� BLDG. DEPT. NO._ <br />{�WNER ❑ AGENT DATE � _ ��� � 9 L <br />APPLICANT/FIRM REPRESENTED �� � �`J / ���� � -' 1 'J � __ __.__ _.___ <br />ADDRESS _ Gl�� J, r . �" �'f�/2F TI /YI�/( [(%AfCITY ��F�E� _--TELEPHONE _�SS-���I1I <br />--- — ---- — � <br />/�lJ$%/1/( . � <br />HEFEdYAPPLIESFORPEFMISSIONTO _ �S___.<tI/D�___i!_YU"R!%a= ct��'�(/�k/A%__ <br />— — -- . -- - -. -- -- - .�:� <br />AT THE FOLLOWING LOCATION �C7 �3�0 (�p/�� ��N� ��7/17f j_��� 7 y_� S'�. 5•w. <br />Atlach live (5) copies of preliminary plans for proposed work. Draw to scale ar.d show the (ollowing as applirable: <br />• Property lines and street identity. • Topographic changes requiring cuts and (lils <br />• Outline and dimensions of existing and other Ihan normal foundation. <br />proposed structures. • On•site drainage systems when required. <br />• Existing and proposed utilities. ' Erosion, control mothods when requlred. <br />' Centerline ol abulting right of way. ' North atrow � <br />- �� �i�V ,/��1� �L_. <br />� �. . _. ___—___--.__ <br />Signeldre ol ApPbcenl <br />PUSUC WC�RKS PERMIT <br />CONDITIONS: <br />I. �koo� ��� <Ir.��.,�:�e ,.-,.•,f v< „�,. �.: n-:. <br />e�. ��.� �la�.,ayG oi brr��ca�c -�o � 4�1�.. \��y�+ <br />p«w„N\ C�� �y. �•�NS��w�t��., b�.. <br />C' YMN�� <br />4� „ , I�cl rr <br />�.. � ��o�` <br />' O f \ \.l 1] y <br />.. �; . ,, ,.�� b7 <br />3� .1'fbfl) �(6c�1:. �.��U �'�N�J�.I I�I��1T"U1� Ivh.f <br />Co� �+r�c��o.-, �i i c Is i� b¢ r�ran a.Y <br />�/ ,C <br />: '�� /�,"'"�" ir�� 1 /% t L <br />OVED FOA CONSTRUCiION - � �� DATL <br />-��_- - ---� � "�"�3 <br />APPROVED AS GONS7 CTED DAT� <br />._. �_— ----. _.. . _ <br />PERMIT IS VALID F�R 1 YEAR <br />EXPIRATION-�—�� `�'� <br />(,�.- 1 l„ � <br />ti.� c�n��.' <br />Ilir wWmsiyned nwnrr licreby agreos lo hold antl 60va he1mIB55 <br />Ih�• Oly OI I1��VIe11 ��o��l .IOY dna 1111 tlplT� IOf tlemepae, coale, <br />e�penses, oi ca isos o� nctlon Ihat mey eiiae WCeusB ol Instellallon <br />aM muinlenence ol Ihe imp�ovemenl or olher riq�bohwey uee <br />hmelo epP��eU Im nnd Iwlher aBroes lo remove eeme upon nollce <br />Irom Ihe Clly nnd to roplacx puhl�c Uro�erty demeped Ihereby. <br />ACKNOWLEDGEMENT OF CONDITIONS <br />� <br />'l;����.t,�g�, f <br />SIGNATUREOF/IPPLIGANT DATE <br />POST ON I CALL FOR INSPECTION <br />259•8811 <br />JOBSITE 24HRS.BEFORECONSTRUCTION <br />1 <br />