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23904 84TH AVE W
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City -of Edmonds.#4
RIGHT-OF-WAY CONST�ZUCTJON
JrhK1VJLJL JL Permit Number.
A. Address or Vicinity of
B. Type of Work (be specific):
Issue Date:
:2 A -N .4,
C. Contractor: Vlew IAJ�� ��7(—Contact:
Mailing Address:
Phone:
4 - 7
State License #: Liability Insurance: Bond: $
D. Building Permit # (if applicable): Side Sewer Permit # (if applicable):
__J
E. F1 Commercial []Subdivision [I City Project W, Utility (PUD, GTE, WNG, CABLE,P
n Multi -Family [:1 Single Family F] Other LTER)l
INSPECTOR: INSPECTOR: IJ
F. Pavement or Concrete Cut: Yes DNo G. Size of Cut:, 4 x q H. Chargt�-$
Ct/7 1�-1 6HOULCEI� 99-\
V 'Y' '0
APP�t�4AN-�TqtT2pO'4r;REACI�4AN* D- SIGN
INDEMNITY. Applicant understands and by his signature to this application, agrees to hold the City ofEdmonds 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 legalproceedings 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
INSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREET PATCH
IS COMPLETED BY CITYFORCES, AT WHICH TIMEA DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THEAPPLICANT
Construction drawingof 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 ve g5=permit requirements and thepink copy of thepermit will be
available on sl e tal
Signature: V"' - - Date:-,. 7
ontractor o�r Agent
i5
L IAL- -DIORIOR TO BEGINNING WORK
FOIC CITY USE ONLY
APPROVED BY:
TIME A UTHORIZED: VOID AFTER DAYS
SPECIAL CONDITIONS:
RIGHT OF WAY DEPOSIT
DISRUPTION FEE/FUND411:
RESTORA17ION FEE:
PERMIT FEE:
TOTALrFEE: :336 o n
COMMENTS: RECEIPT-FE
DATE.
ISSUED BY,7�1
NO WORK SHALL BEGIN PRIOR TO' 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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NOTICE:
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The inform ation'shown on the attached
map(s) was compiled for use by the City Of
Edmonds; its Employees and Consultants.
The CIty of �Edm.qnds does not warrant the
accuracy of anything set for.th on t hese
Map(�_). Any person or entity -requesting a
copy should conduct an independent
0 -ation shown on
inquiry regarding the inf rm
i t limited to,
tfi -rn a p (s), ncluding� but no
t h'e lociation of any sewer stub shown. Such
,not exist and may
sewer stubs may or may I
or may not exist at the location sh ' own
o , nor its
Neither the city of Edrn 'nds.
ernpto-yee-s o-r office.rs sh.all be !.-*,Ia.b.-']-.e for the
information given on this rnap(s), nor for
tation provided based
any one represen
upon . said map(s).