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_Z <br /> 4 <br /> V <br /> i � � V i • � VVI I•� {R <br /> �yeren APPLICATION FOR PUBLIC WORKS PERMIT <br /> Typo or print clearly with Ink p <br /> PRESS HARD- YOU ARE MAKING COPIES PERMIT NO. 0'� y <br /> 01 <br /> PUBLIC WORKS a <br /> EVERETT,WASHINGTON BLDG, DEPT. NO.— �l <br /> DOWNER ❑ AGENT DATE <br /> APPLICANT/FIRM REPRESENTED�AIiil R /►1 �J�VIN -- -- - - ?y3_7o7f oJo$7 <br /> ADDRESS _11 7 7'37_14 rCi7�F S . E .—CITY rrcvECh T-f TELEPHONE <br /> HEREBY APPLIES FOR PERMISSION TO <br /> Mete? �fySc 'tom /� i far! cea�stclrr_� <br /> r do <br /> AT THE FOLLOWING LOCATION //7 — <br /> Attach five(5) copies of preliminary plans for proposed work. Draw to scale and shorn the following as applicable: <br /> • Property lines and street identity. • Topographic changes requiring cuts and fills <br /> • Outline and dimensions of o:Isting and other than normal foundation. <br /> proposed structures. • On-site drainage systems when required. <br /> • Existing and proposed utllitiec. • Erosion control methods when required. <br /> • Centerline of abutting right of Nay. • Nort!t'Arrow 11� <br /> �— t- • nature at A plica t -- <br /> PUBLIC WORKS PERMIT <br /> CONDITIONS: <br /> �i <br /> V1 tAr cc Uva C1 V% - <br /> The undersigned owner hereby agrees to hold and save harmless <br /> the City of Everett tram any and all claims for damagec costs. <br /> expenses,or causes of action that may arise becauv of Installation <br /> and maintenance of the improvement or other right-of-way use <br /> hereto applied for and further agreed to remove same upon notice <br /> / t from the City and to replace public property damaged hereby. <br /> PPR VED F� R CTI N DATE ACKNOWr D:IEMEN CONDITIONS <br /> APPROVED-AS DA}L SIGNATURE OF ZrAN DATE <br /> PERMIT IS VALID FOR 1 YEAR T CALL FOR INSPECTION <br /> POSON 259-8811 <br /> EXPIRATION - '` '} i _ JOBSITE 24 HRS. BEFORE CONSTRUCTION <br />