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8609
24125 89TH PL W
77
. City of Edmonds
RIGHT-OF-WAY CONSTRUCTION
I
PERMIT
Permit Number. ?'7-o?7
Wue Date:
A. Address or Vicinity of Construction:
B. Type of Work (be specific):
C. Contractor:
Mailing Address:,
State License #:
D. Building Permit # (if applicable):
Contact:
Phone:
Liability Insurance: Bond: $
Side Sewer Permit # (if applicable):
E. El Commercial El Subdivision E] City Project [J Utility (PUD, GTE, WNG, CABLE, WATER)
F] Multi -Family 0 Single Family Other
INSPECTOR: INSPECTOR:
F. Pavement or Concrete Cut : 0 Yes []No G. Size of Cut: — x — H. Chargq�_$
APPLICANT TO READ AND SIGN
INDEMNITY: Applicant understands and by his signature to this application to hold the City of Edmonds harmlessftom 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 limited to the defense of any legal proceedings including defense costs and attorneyfees by reason of granting this permit.
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 STREET PATCHIS COMPLETED
BY CITY FORCES, AT 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 above statements and understand the permit requirements and the pink copy of the permit will be
available on site at all timesfor inspection purposes. .
Signature.
Date:
(Contractor or Agent)
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
AP PROVED BY
TIME AUTHORIZED: VOrD AFTER 15h DAYS
RIGHTOFWAY
DISRUPTIONFEEIFUND1,11:
SPECIALCOND(TIONS: RESTORATION FEE:
T OTAL FEE: 00
_RECEIPT.NO
42
ISSUED BY:
FIELD INSPECTION NOTES -
Comments:
1 *4"1. -4, , � , � , !,;�
Dft�gram;
(Fund 111 - Route copy to Street Dept.)
CONTRACTOR CALLED FOR INSPECTION . DYES
Partial Work Inspection by P.W.:
Work Disapproved By: Date:
FINAL APPROVAL BY: Date:
0 NO
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