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CITY COPY
CITY OF EDMONDS
BLDG. DEPT.
CONDITIONAL PERMIT
WORK. DocK
ADDRESS -
OWNER.
APPROVED DATE -
BY
BLDG. OFFICIAL
KEEP THESE STAMPED
PLANS ON JOBSITE FOR
ALL INSPECTIONS
PERMOIT. NO.
-
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CITY OF EDMONDS
PUBLIC WORKS DEPARTMENT rip
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RIGHT - OF - WAY CONSTRUCTION PERNZ,T-�� rn, —
A. eAddress or vicinit f C on
3 .70 y o ons ruc i
so'- 74- A�), W,
9 Owner: DEN ItS &'LIS661L�
Name
2 ?oas- - L) VJ
Mailing Address
City, State'; Zip Code
e Contract6r-
Narne,,
f4d y
Mailing Address
J,V1jf,x,)C)00 U)/?
city" State, Zip Code
Permit No.
Issue Date
0 Permit Issued To:
9 Type of Work to be Done:
I tj 5 r�q L, (_ EW-T 12-� C. r-A C I t- t 71' Es
o Work in Connection With -
El Sub or Plat W Single Family
El Comml. / Ind. 0 Apt. Condo.
0 Pavement Cut: El Ye's I )� No
State Liccnse Number
3 -74 - 211 2�
Telephone Number
* * NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE * *
B. APPLICANT TO READ AND SIGN
INDEMNITY: Applicant understands and by his signature to this application, agrees to hold the City of Edmonds harmless
from any 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 of any legal
proceedings including defense costs, court costs, and attorney fees by reason of granting this permit.
Upon issuance of this permit, the contractor is responsible for workmanship and materials for a period of one year
following the final inspection and acceptance of the restoration by the Engineering Division.
Funds held from the Security Deposit (estimated restoration fee) will be held until the final street patch is completed, at
which time a debit or credit will be processed for issuance to the applicant.
Work is to be inspected.' Restoration to be in accordance with City Code. Traffic Control to be in accordance with Traffic
Section of City Code. Street to be kept clean at all times. A 24 - hour notice is required for inspection by Engineering.
Call 775-2525, extension-e%-*.,;Z59
I understand that this permit at t f oses at all times.
Signature Date
Owner or Agent 0
THIS PERMIT MUST BE POSTED AT THE JOB SITE FOR INSPECTION PURPOSES
CALL DIAL - DIG PRIOR TO BEGINNING WORK
C. Issued By:
Time Authorized: 09id after —days
Speclial Conditions:
Ammendments:
Permit Fee: - - -----
Security Deposit:
Receipt No.:
Fund I I I Fee:
Street Cut Dimensions
x —
* * NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE * *
Eng. Div. December 1978
.1 * ' ,
FIELD INSPECTION NOTES (Fund 111 - Route conv to Street Dent.]
Comments:
Diagram:
Contractor called for inspection Yes NO
I
Nork Disapproved By: Date: Bv: Date:
Work Approved By: —Date:
Inspector:
Ena. Div. December 1978
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99 Lot Per Subdiv"Sion
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constniqtion Pc Zcc!tiirc
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it
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Spcdal Pcquircments 14-stcd in inciad to Building f�-p,-)rtmcnt
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13V Date
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