1206 OLYMPIC AVE (2).pdfCITY OF EDMONDS
PUBLIC WORKS DEPARTMENT
RIGHT - OF - WAY CONSTRUCTION PERMIT
A. ®Address or vicinity of Construction
1. 0L \J Vv+ 1Pi 6 P�\J
® Owner:
Namc 1l 1� � � � ►f l �� 1-1
Nv ailing Address
L10 w'r-) slz� oZ0
City, State, Zip Code
e Contractor: !r--- \_ I 1 J
Permit No.
r`t 1982. Issue Date
Dir. Of Public. Works
® Permit Issued To:
® Type of Work to be Done:'Te C" P V\)
iNSTAu- !21C VJtP, S
® Work in Connection With:
❑ Sub or Plat 'Single Family
Cl Comml. / Ind. ❑ Apt. Condo.
® Pavement Cut: ❑ Yes No
Name 1/Q� C
Mailing Address State License Number
Ctty, State, Zip Code Telephone Number
* * NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE
B. APPLICANT TO READ AND SIGN
INDEMNITY: Applicant understands and by his signature to this application, agrees to hold the City of Edmonds harmless
from any 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, court costs, and attorney fees by reason of granting this permit.
Upon issuance of this permit, the contractor is responsible for workmanship and materials for a period of one year
following the final inspection and acceptance of the restoration by the Engineering Division.
Funds held from the Security Deposit (estimated restoration fee) will be held until the final street patch is completed, at
which time a debit or credit will be processed for issuance to the applicant.
Work is to be inspected. Restoration to be in accordance with City Code. Traffic Control to be in accordance with Traffic
Section of City Code. Street to be kept clean at all times. A 24 -'hour notice is required for inspection by Engineering.
Call 775-2525, extension 220.
I understand that this permit must be available at the job
Signature:
Owner or
inspection purposes at all times.
Date � I ^ 2 -
�r �k THIS PERMIT MUST BE POSTED AT THE JOB SITE FOR INSPECTION PURPOSES
CALL DIAL - DIG PRIOR TO BEGINNING WORK
C. Issued By:�J2tictifk-7 -
Time Authorized: Void t tf erdays
Special Conditions:
Ammendments:
tin
Permit Fee:
Security Deposit:
Receipt No.:
Fund 111 Fee:
Street Cut Dimensions
X_
* * NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE * *
Eng. Div. December 1978
CITY OF EDMONDS
PUBLIC WORKS DEPARTMENT
TO:
LU
D
a
W
o
SUSPENSE DATE:
/
Investigate
and Report
Take Appropriate
Action
Prepare
letter/memo
for my signature
For Information
Previously Ref'd
Status of Action?
�%�
Return to:
OFFICE ADMINISTRATOR
BUILDINGS & GROUNDS DIV. SUPERVISOR
EQUIPMENT RENTAL DIV. SUPERVISOR
STREET DIVISION SUPERVISOR
WATER/SEWER DIVISION SUPERVISOR
TREATMENT PLANT DIV. SUPERVISOR
COMMENTS:
FROM:
DATE:
IV