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RIGHT-OF-WAY CONSTRUCTION
PERMIT
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A. Addre�s or Vi,cinity of Construction:
B. Type of Work (be specific):
C. Contractor:nl
Mailing Address:-,z - F__:I7_f5
State License #:
D. Building Permit # (if applicable):
Permit Number. ego
Usue Date:
Liability Insurance: Bond:. $
Side Sewer Permit # (if applicable):
E. El Commercial [I Subdivision 'Utility (PUD, GTE, WNG, CABLC, WATER
Multi -Family [:] Single Family Other
El City Project \171'
INSPECTOR: INSPECTOR:
F. Pavement qC� �ncre Cut: PYes 0No G.- Size of Cut: x H. Chargc$
APPLICANT TO READ AND SIGN
- INDEMN17-f.- Applicant understands and by his signature to this application to hold the City of Edmonds harmlessfrom injuries, damages, or claims ofany
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 attorneyfees by reason of granting this permit.
THE CONTRA CTOR IS RESPONSIBLE FOR WORKMA NSHIP AND MA TERIA LS FOR A PERIOD OF ONE YEA R FOLIO WING THE FINA L INSPEC-
TION AND ACCEPTANCE OF THE WORK. ESTIMATED RESTORATION FEES WILL BE HELD UNTIL7THE FINAL STREETPATCHIS 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 streetcuttrench work shall be patched with -asphalt or City approved material priortothe end ofthe workingday;
NO EXCEPTIONS.
I h d hJ above statements and understand the permit requirements and the pink cop'y bftfie�'pZ!rmit will be
ave rea'
available on s e at all t* esfio 1i . ef* '"rposes.
J7Signature: Date: 1Dz::;- (�M*19
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CALL DIAL-r-DO IG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY�. A/ RIGHT OF WAY FEE: WAI
TIME AUTHORIZED: VOID AFTER 6116) DAYS DISRUPTIONFEE/FUND III:
SPECIAL CONDITIONS:
AJ
RESTORATION FEE:
T OTAL FEE: —
RECEIPT NO.:
ISSUED BY:
7-
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE Eng. Div 1997
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FIELD INSPECTION NOTES, (Fund 11f - Rdute copy to Street Dept.)
Comnients..,
CONTRACTOR CALLED FOR INSPECTION El YES E-T'NO
Partial Work Inspection by P.W.:
Work Disapproved By: Date:
FINAL APPROVAL BY: Date:
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