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22604 106TH AVE W
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C. Contractor:
City of Edmonds
RIGHT-OF-WAY CONSTRUCTION
PERMIT
A. Address or Vicinity of Construction:
Permit Number.
Usue Date:
22604 106th Av W,
03 fi to
C� Work , * Cl!ar Rossible water short on 344
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Of V6CE e Ich-ing; i10 _., PakV'oVsVr8eMad'S/
iwjsyr!r U si e p io'6T82)ad:,
MW6323008) be W
Puget SounS Energy/Gas Contace—Margie mraz (BYD-01W)
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MailingAddress: P- 0- Noz 1869 Phone: (206) 224-2139
State Lic . ense #: Seattle, WA 98111 Liability Insurance: — Bond: $
WASHING285CB
D. Building Permit # (if applicable): _
Side Sewer Permit # (if applicable):
E. E] Commercial E) Subdivision El.� qj!YPF-�ject yD,4GTE, WNG, CABLE, WATER)
Multi-_Fami'lY' El" -Single Pa� lY Othe*ri
INSPECTOR: INSPECTOR:
F. Pavement or Concrete Cut U Yes YNo G. Size of Cut: x H. Charge.,,$
EAD AN ',�IG
APPLICANT TO A N
INDEMNITY. Applicant understands and by his signature to this application, agrees to (�_w
,-. ol�IcCityofFdmondsharmlesi�fiominj��esI
claims of any kind or description whatsoever, foreseen or unforeseen, that may be made agai,6t the City of Edmonds, or ainy'of its departments or'
I I
employees, including or not limited to the defense ofany legalproceedings including def�nae costs, and attorney fees by reason ofgranting thispermit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL
INSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREET PATCH
IS COMPLETEO BY CITY FORCES, AT WHICH TIMEA DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THEAPPLICANT.
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.
Tiaffic 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.
Ihave read the above statements and understand thepermit requirements and thepink copy of thepermit will be
available on -site at all times for inspection p?Ar.p9qqs�.,
Signature- Date: 8/29/97
(Contr"a"ctor or Agent) r
Coocr*dd natort Dist4bution
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE -ONLY
APPROVED BY: RIGHT OF WAY �DEPOSIT
TIME AUTHORIZED: VOID AFTER DAYS DISRUPTION FEE/FUND Ill -
SPECIAL CONDITIONS: A/4 RESTORATION'FEk:
PERMIT FEE:
COMMENTS:
DATE:
TOTAL,FEE:
RECEIPT FEE:
ISSUED BY:
NO WORK SHALL BEGIN PRIOR TU PERMIT ISSUANCE
Eng. Div.. 1994
FIELD INSPECTION NOTES
Comments:
Diagram.:
(Fund 111 - Route copy to Street Dept.)
CONTRACTOR CALLED FOR INSPECTION El YES El NO
Partial Work Inspection by P.W.:
Work Disapproved By: Date:
FINAL APPROVAL BY: Date:
. ... . ...... . .
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