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23701 104TH AVE W
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Cit� pf E&nonds
RIGYff-OF-WAY CONSTRUMON
FERMIT. ;V 175
Petit N.b..
Lwue Date- 7 - c;�-.
A- Address or Vicinity of Construction:
B. Type of Work (be specific):
C. Contractor. (01-YA4 Contact:
Mailing Address: wofl� —1-14 —1-761
Q 'KPhone:
State License #: Liability Insurance: Bond- $
D. Mlding Permit # (if applicable): Side Sewer Permit # (if applicable):
E. 0 Commercial 0 Subdivision [I City Project tility (PUD, GTE, WNG, CABLE,
0 Multi -Family 0 Single Family 0 Other r
INSPECTOFU INSPECTOR- Vy
F. Pavement or Concrete Cut )JYes C]No G. Size of Cut x(, H.- Charge_$
10
i6FN4U77 Y
"PLICANT TO READ aZG�
]NOFMNITY., Applicantunderstands and by his signature to thisapplication, agrees to hold the City ofEdmondsharmless from iWuries, damages, or
claim of any kind or description whatsoever, foreseen or unforeseen, that may be made against the City of Edinands, or any of its departments or
employees, including or not limited to the defense of any legalproceedwfa inchuhng defense costs, and attorney fees by reason ofgranting this permit.
WIJV=E FWA
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATER1ALS,,F0AA,.E�ERZ
,W,Or_ ONE YEAR PO
17VSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE;VAL S PAWH
IS COMPLETED BYCITYPORCES, AT WHICH TIMEA DEBIT OR CREDIT WILL BEPROCGSSED�JVISSU4NCE 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.
rPraffic 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 workingday;
NO EXCEPTIONS.
Ihave,readthe d thepermit requirements and thepink copyof thepermit will be
available on si;J es. (
Signature: iF1 r Date:
V I.-"-Iltrac rorAgent)
M91 2(L-& .
�-ML DIA, R TO BEGINNING WORK
14- liar.
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B III rG— wffrko DE IT;.
AYS DISRUPTIOWTEE/FUND 11
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ONDITIONS. STORAIT
REMItAll
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1 4 �i
I TE' "ISSUED BY -
NO WORK SHALL BEGIN PRIOR TO'PEMAMUSUANCE
En& Div. 1994
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