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19423 86TH AVE W
CITY OF'EDMONDSO
RKS DEPARTMENT, ENGINEERING DIVISION
STREEtIftfl Cr)D DTr-UT f)i: . HAv . rrv. . i(1TniirTTr)t.i nrr)rATT
THIS PERMIT MUST. BE AVAILABLE AT THE JOB SITE FOR INSPECTION PURPOSES
Appl,icantto Complete Parts A And B
A. Permit to be issued t o 0
For Work at:(address or vicinity) ey V__-5
Type of Work to.be done:
(attach drawing when applicAle
Tim . e Required Start: ge, < 7 —Finish:
Owner: 7,15 /,j' V q A
Name
�141
Mailing Address
r:j. 6.41-A
.City . State Zip Telephone Number
Contractor:
Name
2 g--A L/
Mail* Address
- - z X, a -A /. -, 0J, k
City State Zip
V- 2
State License Number
`7 7 �(-- ) :�, 6 &
Telephone Number
NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE **
B, INDEMNITY: Applicant Understands and bX 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 applicant or 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 subject to inspection.and restoration'in accordance with City Code. A
24-hour notice is required for inspection by Engineering. Call 775-2525, ext. 220.
I understand that this permit must be available at the job site for inspection
purposes at -all times.
S i g n a t u r e Date: Y11
Owner or Agent
I TO BE COMPLETED BY ISSUING AGENCY:
Date Issued: Permit No.: 7-&! Fee
Security Bond:
Time Authorized: -
APPROVED BY
Date:
�� I
77,
0 0
Time
A= -
CITY OF EDMOND S",
....-,-.PUB& *KS DEPAR'_ I N_ *I NWI V I S
TMENT, ENG ION
FOR RIGHT-OF-11AY CO3PLS_TPUCTION PFRr1IT
"rRE
NU31 6L AVAILA;BLE AT THE JOB",SITE FOR INSPECTION PURPOSES
Applicant to Complete Parts A and B
A. Permit to be issued to:
For Work at :(address or vicinity)
(�//V 7—
Type of Work to be done:
(attach drawing when applicable)
Time Required -- Start: Finish:
Owner: Elvo' n.
Name
OIL,) /'F
_A16'ot, /
Mailing Address-
-7 7,,--/
city State Zip Telephode Number
Contractor:
Name State License Number
Mailing Address
City State Zip Telephone Number
B, INDE�LNITY: 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 o ' r description whatsoever, ioreseen' or unforeseen, that may -be made against
the applicant or 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 I 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 subject to inspection and restoration in accordance with City Code. A
24-hour notice is required for inspection by Engineering. Call 775-2525, ext. 220.
I understand that this permit must be available at the job site for inspection
purposes at all times.
Signature:__J_1_ Date: . 11__ZZ - ;7,�?'
Owner or Agent
TO BE CO�IPLETED BY ISSUING AGENCY:
Date Issued:--- ermit No.: Fee:
Security Bond: .- .. -..-2Z
Authorized: