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�i APPLICATION FOR PUBLIC WORKS PERMIT <br />Type or Print clearly with ink <br />PRESS HARD - YOU ARE MAKING COPIES �� <br />PUBLIC WORKS PERMIT NO. <br />.EVERETT, WASHINg ON <br />El OWNER [GENT DATE 2�IZ3I�Z BLDG. DEPT. NO... _ <br />APPLICANT/FIRM REPRESENTED <br />5i <br />ADDRESS 1 J (off Il _�CITY[:1ff�GIG12 TELEPHONES 7 `1 33 <br />1 <br />HEREBY APPLIES FOR PERMISSION TO 1,A 1 ��\_ Ni lFii L-I/�:- S <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 />• Property lines and street identity. • 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 rrow <br />1 <br />-- - -- Signature of APPlloant <br />PUBLIC WORKS PERMIT <br />CONDITIONS: <br />_ Pet P�aNs ��PCuv.J1 3dr2_ <br />Ire`C'e i�� C`ur 6 �tiNe. 5ee�l� �u�� b� <br />((a,. `cc ���ar�c�1 T 0. S 1S 4, 5a -tK J— <br />r- rr*NS ^JJ �NG CL4.r7Y �X�QNS1oH 1� <br />O :�U r �L I S Y1 t7 t Q,:/I �O We [X I <br />.�e rep+,.�t��� OV SOw -llr�s/.J o" <br />O� i'1 fq�PSf' Chf`4`an610 ., J01.r/.�-, HPa.J S, rIr t" IiG <br />� I 0 H s -�,� s e (7 01^ <br />i <br />The undersigned owner hereby agrees to hold and save harmless <br />the City of Everett from any and all claims for damages, costs, <br />expenses, Or CPOses Of action that may arise because Of Installation <br />and maintenance of the Improvement or other right of -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 />-AP <br />P F O RUCTION DATE'a77'`.�KJN_O}'—W{ljr.-E--D)G--1tEME/NT OF CONDITIONS p <br />.. C7E DA - __,91GNA E4FAPPLICANfi DATE <br />PERMIT IS VALID OR 1 YEAR CALL FOR INSPECTION <br />POST ON 1 259.8811 <br />EXPIRATION __ JOBSITE 24 HRS. BEFORE CONSTRUCTION <br />