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10523 ROBIN HOOD
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_ - City' of ' Eciriionds.
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RIGHT -OF -AY CONSTRUCTION "
P RMIT, 1. Permit Number: �- 3
Y ` Issue Date:
A. Address or Vicinity of
B. Type of Work (be speci
7'rn C. 189
C., Contractor: (Jl.i�nftc Y(EI(`�
Mailing Address: 11(1,4V
State License #:
D. Building Permit # (if applicable):
Phone: 405 -7 4 %%/�
Liability Insurance: Bond: $
Side Sewer Permit # (if applicable):
E. ❑ Commercial ❑ Subdivision ❑ City Project Utility (PUD, GTE, WNG, CABLE,
❑ Multi -Family ❑ Single Family ❑ Other
INSPECTOR: 1 INSPECTOR: Q1J
F_ Pavement or Concrete Cut : [I Yes g $ l �No G. Size of Cut: I ~' x H.' Char . e
APPLICANT TO READ .A, 1ND SIGN
{ INDEMNITY.- Applicant understands and by his signature to this application to hold the City of Edmonds harmless from injuries, damages, or.claims of any
kind or description whatsoever, foreseen or unforeseen, that may be made against the City of Edmonds, or any, of its departments or
employees, including or not limited to the defense of any legal proceedings including defense costs and attorney fees by reason of granting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL INSPEC-
TION AND ACCEPTANCE OF THE WORK. ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE. FINAL STREET PATCH IS COMPLETED
BY CITY FORCES; AT WHICH TIME A DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT.
Two sets of construction drawings of proposed work required with permit application.
A 24 hour notice is required for inspection. Please call the Engineering Division, 771-0220.
Work 'and material is to be inspected during progress and at completion.
Restoration is to be in accordance with City Codes.
Street shall be kept clean at all times.
Traffic Control and Public Safety.shall be, in accordance with City regulations as required by the City Engineer.
All street cut trench work shall be'patched with asphalt or City approved material prior to the end of the working day;
NO EXCEPTIONS.
I have read the above statements and understand the permit requirements and the pink copy the permit will be
available on sit at all t' es fo i i purposes.
Signature. Date:
(Contractor o Agent)
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY: 'QW � ; RIGHT OF WAY FEE:
TIME AUTHORIZED: VOFD AFTER J2.0 DAYS DISRUPTION FEE/FUND 11 I:
SPECIAL CONDITIONS: _ _,P/ At RESTORATION FEE:
T OTAL FEE:
M
ISSUED BY:
NO WORK SHALL BEGIN IFJOR TO;PERMIT ISSUANCE Eng. Div 1997
FIELD INSPECTION NOTES (Fund 111 - Route copy to Street Dept.)
Comments
kit: , . ,,, i. ` i w:
Diagram
CONTRACTOR CALLED FOR INSPECTION ❑ YES ❑ NO
Partial Work Inspection by P.W.:
Work Disapproved By: Date:
FINAL APPROVAL BY: Date:
6
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NON
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