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24026 107TH PL W
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City of Edmonds
RIGHT-OF-WAY CONSTRUCTION
PERMIT
�ermit Number.
Issue Date: ��69_ �:35_9
0400J��7 7V F?
A. Address or Vicinity of Construction: 107
B. Type of Work (be specific): JZeL_CJfA7Z,', WAJE�6Z ME77�
C. Contracton'OLYMPICC"', vew Contact:
Mailing Address: �a_-3_10S i�4:7)Mb&&25
Phone: -77
State License #: Liability Insurance: _ Bond: $
D. Building Permit # (if applicable):
Side Sewer Permit # (if applicable):
E. [:]Commercial []Subdivision E) City Project Utility (PUD, GTE, WNG, CABI_4:-.�/W�VrATER)
n Multi -Family [] SingleFamily E] Other
INSPECTOR: INSPECTOR:
x
F. Pavement or Concrete Cut 0 Yes )XNo G. Size of Cut: H. Chargq-$
APPLICANT TO READ AND SIGN
INDEMNITY. Applicant understands and by his signature to this application, agrees to hold t]" City ofEdmonds harmles from in uries, damages, or
claims of any kind or description whatsoever, foreseen or unforeseen, that may be made against the City of Edmond8, 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 CITY FORCES, AT WHICH TIME A DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT.
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 dhLy;
NO EXCEPTIONS.
Ihavereadthea o e statements and wzderstand the permit requirements and the pink copy of thepermit will be
11 tim 1p
available on site Ot "alltim for &S , C rposes.
Signature: Date: 0-7
(CoRtractor r _ W'ent) �V
E-AJ454q*FT14 14 IC
T
'.LL IAL- - I IOR TO BEGINNING WO�K
FOR CITY USE, ONLY
APPROVED BY. Flyd RIG'HT OF WAY DEPOSIT
TIME A UTHORIZED: VOID AFTER —DAYS
SPECIAL CONDITIONS: VA
COMMENTS:
DISRUPTION FEE/FUND Ill:
RESTORATION FEE:
PERMrrFEE:,, 10.
TOTAL FEE:
RECEIPT FEE:
to
DATE:
ISSUED
NO WORK SHALL BEGIN PRIOR'TU, PERMIT ISSUANCE Eng. Div. 1994
FIELD INSPECTION NOTES
Comments:
Diagram.:
CONTRACTOR CALLED FOR INSPECTION
Partial Work Inspection by P.W.:
Work Disapproved By:
FINAL APPROVAL BY:
(Fund 111 - Route copy to Street Dept.)
El YES
Date:
Date:
El NO