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1, PERMIT Permit Number. 9
A. Address or Vicinity of Con!
B. Type of Work (be specific):
C. Contractor: 0�rl yfew
Mailing Address:
State License #:
D. Building Permit # (if applicable):
Lssue Date:
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Contact: At2�� W/ /
Phone: YZ
A 772�0
Liability Insurance: Bond: $
Side Sewei Permit # (if applicable):
E. E] Commercial E] Subdivision El City Project tility (PUD, GTE, WNG, CABLE,&_ ATER)
n Multi -Family EJ Single Family Other KU
INSPECTOR: INSPECTOR: RLJ
F. Pavement or Concrete Cut Yes MNO G. Size of Cut: x Chargi�,$,
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Ox q100 APPSEARTKO 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 limitedlo the defense of any'�egal proceedings including defense -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 INSPEC-
TION AND ACCEPTANCE Of THE WORK ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREETPATCHIS COMPLETED
BY CITY FORCES, AX WHICH TIME A DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT
Two sets of construction drawings 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 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 abov ' "�atements and understand the permit requirements and the pink copy of the permit will be
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available on site at al tr, esfo , nspe
Signature: IpmJ Date
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A QN0 BEGINNING WORK
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NO WORK SHALL BEGIN PRIOR TO%PERMIT ISSUANCE Eng. Div 1997
FIELD INSPECTION NOTES
Comments:
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(Fund 111 - 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:
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