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15901 68TH AVE W
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City . of (Edrnonds';
RIGHT-OF-WAY CONSTRUCTION -"-
PERMIT Permit Number.
Issue Date:
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A. Address or Vicinity of Construction: 1!5901 68 Ay W (9618988 )
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9p B. Type of Work (tie specific): Install Service
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C. Contractor: Washington Natural GAs Contact: be88Y floyd :
Mailing Address: 1122 75 St SW Everett Phone: 356-7500 X7596
State License #: 98203 Liability Insurance: Bond: $
D. Building Permit # (if applicable): Side Sewer Permit # (if applicable):
E. ❑ Commercial ❑ Subdivision ❑ City Project] Utility (PUD, GTE, WNG, CABLE, WATER)
❑ Multi -Family ❑ Single Family ❑ Other
INSPECTOR: M1 INSPECTOR:
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F. Pavement or concrete tut : xis Yes ur4o ti. zitze of tvt: i x Ii. c+narge �
cut )
APPLICANT TO READ SIGN
INDEMNITY: Applicant understands and byrhis signature to this application, agrees to hold the City of Edmonds harm li from injuiies, 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 ojany legs[proceedings including defenagco, and attorney fees by r o of ting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR Ar PEOD OF ONE YEAR FOLLOWING THE FINAL
INSPECTION AND ACCEPTANCE OF THE WORK. ESTIMATED RESTORATION FEES 1WILL 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.
Construction drawing 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 ditches 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 of the permit will be
available on site at all times for inspection purposes.
-Signature: �� Date: 8-2 t -96
Tconiract6r Or Age )
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
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I ` FOR CITY USE ONLY
'APPROVED BY: `;t RIGHT OF WAY DEPOSIT
TIME AUTHORIZED: VOID AFTER _ ,DA-YS . DISRUPTION FEE/FUND III:
SPECIAL CONDITIONS: U 6— RESTORATION FEE:
PERMIT FEE:
COMMENTS:
TOTAL FEE:
RECEIPT FEE:
ISSUED BY;_
NO WORK SHALL BEGIN PRIOR TO :;PERMIT ISSUANCE
Eng. Div. 1994
FIELD INSPECTION NOTES
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Comments
1
I Diagram
CONTRACTOR CALLED FOR INSPECTION
Partial Work Inspection by P.W.:
Work Disapproved By:
FINAL APPROVAL BY:
(Fund 111 - Route copy to Street Dept.)
❑ YES
Date:
Date:
❑ NO
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Addendum to: City of Edmonds
Right of Way
Permit Application
Submitted by: UVT
Mmineeritng Aide
L Gas
Watermair} depth `$�L6
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Washington Natural Gas Company
1122 75th Street S.W., Everett, Washington 98203, (206) 355-3331
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Addendum to: City of Edmonds
Right of Way
Permit Application
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Submitted by:eY
EnQineerin.e Aide
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Watermain depth \'DV6
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Washington Natural Gas Company
1122 75th Street S.W., Everett, Washington 98203, (206) 355-3331
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Addendum to: City of Edmonds
Bight of Way
Permit Application
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Submitted by: ,
EnttineerinA Aide
. Gas
Watermai depth 6;0 �rf
Agas main „
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55 19(0 (88
5°lal AVK1
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Gas
-SS-
Sewer
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Water hydrant
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Water valve
Washington Natural Gas Company
1122 75th Street S.W., Everett, Washington 98203, (206) 355-3331