23627 104TH AVE W.PDFiiiiii lill
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23627 104TH AVE W
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9 0 - 19
C. Contractor: (1-A-
Mailing Address:
State License #:
City of Edmonds''.'.
RIGHT-OF-WAY CONSTRUCTION
MKIVIL11 Permit Number.
Issue Date: -7
A. Address or Vicinity of Construction:
,- -I-
B. Type of Work (be specific):
Liability Insurance: - - - - Bond:$
D. Building Permit # (if applicable): Side Sewer Permit # (if applicable):
E. Commercial Subdivision ri city Project tility (PUD, GTE, WNG, CABLE, AC�-TER)
Multi -Family Single Family n Other
INSPECTOR: INSPECTOR:
F. Pavement or Concrete Cut: XYes []No G. Size of Cut&y, X,/, H. Chargt�,$
a-x -:3
APPLICANT TO READ' , &M, 4Gk
INDEMNITY. Applicant understands and by his signature to this application, agrees to hold the City ofEdmondg harmless from injuries, 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 ofany legalproceedin#s including defense costs, and attorney fees by reason ofgrantingthispermit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERJALS\Fjy�A��EW ON V9 � P
ffl_DA,M, E AR OL
UNTIL THE ;Lftq
,J EF V
A
INSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES WILL BE HELD FI. ALST TPATCH
IS COMPLETED BY CITY FORCES, AT WHICH TIMEA DEBIT OR CREDIT WILL BE PRocEssEb�501VISSUANCE 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.
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 permit requirements and thepink copy of thepermit will be
available on si
Signature: iiffii7l , Date:
v (C tra�w-r' ovr Aient)
L L LV
DIAL- WR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY: I A RIGHT OF WAY DEPOSIT
TIME AUTHORIZED: VOID AFTER UA-YS DI SRUPTION,FEE/F UND III:
SPECIAL CONDITIONS- RESTORATION FEE:
PERMIT FEE
TOTAL.FEE:
COMMENTS: COM� RECEIPT FEE:
DATE: ISSUED,BY:,
.J�
W
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Eng. Div. 1994
FIELD INSPECT ION NOTES
Comments:
Diagram.:
(Fund Ill - Route copy to Street Dept.)
CONTRACTOR CALLED FOR INSPECTION El YES
Partial Work Inspection by P.W.:
Work Disapproved By: Date:
FINAL APPROVAL BY: Date:
D NO
-��Nv 01
2 L-2
I--: . ...........................
NOTICE:
No warranty of accuracy.
The information shown on the attached map(s)
was compiled for use by the City of Edmonds,
its Employees and Consultants. The City of
Edmonds does not warrant the accuracy of
anything set forth on these map(s). Any person
or entity requesting a copy should conduct an
independent inquiry regarding the information
shown on the map(s), including, but not limited
to, the location of any sewer stub shown. Such
sewer stubs may or may not exist and may or
may not exist at the location shown. Neither
the City of Edmonds nor its employees or
officers shall be liable for the information given
on map(s), nor for any one representation
provided based upon said map(s).