22511 80TH AVE W.PDF111111111111
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22511 80TH AVE W
Inc. -'JSok3
Cit of. Edmonds
RIGHT-OF-WAY CONSTRUCTION
PEIMIT Permit Number.
Lssue Date: A
A. Address or Vicinity of Construction: _J241CO// 7%
B. Type of Work (be specific):
C. Contractor:
Mailing Address:
State License #: J
D. Building Permit # (if applicable):
Contact:
Phone:
Liability Insurance: Bond: $
Side Sewer Permit # (if applicable):
E. E] Commercial Subdivision I I
El City Project X Utility (PUD, GTE, WNG, CABLE, WATER)
E] Multi -Family Single Family n Other
INSPECTOR: INSPECTOR:
F. Pavement or Concrete Cut: 0 Yes 0No G. Size of Cut: — x — H. Chargq�_$
APPLICANT TO READ AND SIGN
INDEMNITY: 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 allorneyfees 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-
T1dN A ' ND ACCEPTANCE OF THE WORK. ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREETPATCHIS CbMPLETED
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 w.ith 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 of the permit will be
available on site at all times r inspection purposes.
fo
Signature:
Date:
(Contractor or Agent)
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY. /4 RIGHT OF WAY FEE:
TIME AUTHORIZED: VOID AIR DAYS DISRUPTION FEEIFUND I 11:
SPECIAL CONDITIONS: RESTORATION FEE:
TOTALFEE:
RECEIPTNO.: A
.111 ISSUEP13)"'.:
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSIJANCE Eng. Div 1997
FIELD INSP I ECTION NOTES (Fund 111 Route copy to Street Dept.)
Diagram.:
CONTRACTOR, CALLED FOR INSPECTION �[J-yvs E-1 NO
Partial Work Inspection b�-P.W.:
Work Disapproved By:. Date:
FINAL APPROVAL BY: Date: