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1 <br />p APPLICATION FOR PUBLIC WORKS PERMIT <br />�i Type or print clearly with ink <br />PRESS HARD - YOU ARE MAKING COPIES <br />PUBLIC WORKS PERMIT NO. <br />EVERETT. WASHI TON t� <br />O OWNER AGENT DATE 8Z S BLDG. DEPT. NO. <br />i <br />APPLICANT/FIRM REPRESENTED <br />tit.. <br />ADDRESSCITY <br />TEL HONE Z !7 <br />HEREBY APPLIES FOR PERMISSION TO ,�ryri�. _ _ . , /r <br />AT THE FOLLOWING LOCATION <br />Attach five (5) copies of preliminary plans for proposed work. Draw to scale and show the following as applicable: <br />• • Prop lines and si�ra entity, • ToOPN hic changes requiring cuts and fills <br />Outline an noes of existing and other tha alioundation. <br />propose at uct ' On -site i ag�e//s�yste required. <br />• Existi nd proposed u i 9. ' Er ' co rolMelhedSYVhen req C erline of abutting right OI Way. arrnw <br />CONDITIONS: <br />PU <br />�.. Xez 1 s l� cticn <br />-rr,�,o•�c �� r- <br />PERMIT IS VALID FOR'R <br />oC)4P, <br />VI <br />exceed <br />The undersigned owner hereby agrees to hold and save harmless <br />the City of Everett from any and ae claims for damage,, costs. <br />expense uses of action that may arise because of Installation <br />antl Inlenanc of Iha Improvement or other right-of-way use <br />here) ap Ted for a d further agrees to remove same upon notice <br />Irom the ity and 1 replace public property damaged thereby. <br />_NATE—___ — <br />POST ON I I CALL FOR INSPECTION <br />V 250.8811 <br />JORRITF nw rnn nrr r�n�nnunrrnri+�er�u <br />a <br />1 <br />J <br />