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Date <br />Pl� <br />Print or Type Only <br />�� - �'-z� s <br />Appliwtlon For <br />WORKS F+ERMIT <br />v.e�cwo�r.� a��mn • I � Cl <br />ewc oeo�. • <br />�,o�K wa... �„ � <br />,o,.� F.. <br />�....00�...�.b s <br />e,u.c.o�. f _ <br />Citv of Everett Pinehurst Neiahborhocd Associatton <br />Owner MaiNngAtlCress City Zip Phone <br />Steve MacNeill 1919 konroe <br />Wq 98203 355-895! �4�0 <br />Lp <br />DeecribeProOosa�Work o:..,.�..... Nuinhhnrhnnd AcmNat;nn Aa�ir`P� tn imnf'OVP thB Slttifla DdPk <br />a h sta d aAdrass�� raN ing and m i ta' ' g 76" hi9h rodar clat fanre nf <br />ProjeQ Address �il known) <br />Altach tour (4) copiaa ol plana lor propased work- Draw to scal5 antl note Ihe I011owinB as appliwble: �— <br />• �roperty Lines • Cenledine ol sireel <br />• Outline enE Cimenai�ns ol all esis�inB aud • Indiwle Norlh <br />praposad atructurea an t�e lat • S�ow any proposetl Bratlin8 c�an0es <br />• Exlstin0 anE pro0osetl utililles • S�ow measuremenls <br />PERMIT CONDITIONS � <br />1. All call9 fOr Inepettlon shall Ee mede 24 hfA in edvBnce - phCne 2$9-8870. <br />2. All vrollt ehell be peAormetl in aaortlance with t�ls permlt and cunent City ol Everel� Design end Construcllor <br />staoaams ana soecirceuons <br />3. Call Locetlon Undargrountl Service 48 hrs. belore you Elp. TOLL FHEE NUMBEH 1•BOO4245555. <br />�� 1�S �r a�rav.ed �%u� d�-{w,d /0-23'9L <br />Dale <br />ACKNOWLEOGEMENT OF CONDITIONS <br />` <br />� <br />T�n unCersignetl owner/ap0licanl �ereby ag�ees to holtl anC save �arm� <br />less Ihe City ol Everett Iwm any and all claims lor Oamaqe& costs, <br />eKpense& or causes ol action ihal may arise because ol in5iellation <br />antl maintenence o� t�e improvemenl or other right�oi-way use �erelo <br />eOGlietl lor enE lurl�er agrees to remove same upon no�ice Irom Ihe <br />Cily anE lo replace Oublic property tlemaqetl t�ereby. <br />FINHL INSPECTION Oete <br />AOPmvetl es Constmcted Signa W ie of Applicant Date <br />��PUBLIC WORNS OEPARTMENT WORK AUTMORIZED BY THIS PERMIT MUST BE STARTEO WITMIN <br />9400La0er5ireet 1B0 DAYS OF DATE PERMIT IS ISSUED ANO THEREAFTEF �S TO <br />EverelL WABR'Ot BE DILIGENTLV PUR911E0 TO COMPLETION. THIS PERMIT MAV 9E <br />Phoner PS! 8610 CANCELLED BY THE GTV UPON ANY STOPPAGE OF W OFK ON THIS <br />PROJECT OVER 90 DAVS OURATION. <br />