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24216 101 ST AVE W
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City of Edmonds Permit No:
RIGHT-OV WAY CONSTRUCTION PERMIT Issue Date:
A. Address or Vicinity of Construction: 16 () /4 W 24 ? EL 1 2 q2 PL21t Zq I X. 101,4 ilL� kJ
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B. Type of Work (be specifiic):
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YEL WATF& M 4- /A)
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C. Contractordl�"Ifi 1/1 Jez� u4et!ja Contact:
Mailing Address: Z 3 7 2-5- ��,060)Q-2� Phone: 776
State License
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D. Building Permit # (if applicable):
Liability Insurance: Bond: $
Side Sewer Permit # (if applicable
E. E] Commercial [-] Subdivision [] City Project E] EUC (PUD, GTE, PSE, CHAMBERS,(!��b
F� Multi -Family E] Single Family F] Other
INSPECTOR----
F. PAVEMENT: YES NO G. SIZE OF CUT x H. Charge: $
CONCRETE CUT: YES NO
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IDEMNITY.- Applicant understands by hislher signature to this application helshe holds the City of Edmonds harmlessfrom injuries,
Wamages 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 but not limited to the defense of any legal proceedings including defense costs and
attorneyfees by reason ofgranting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERJALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL
INSPECTION A" ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREET PATCH IS
COMPLETED BYCITYFORCES, AT WHICH TIMEA DEBITOR CREDIT WILL BEPROCESSED FOR ISSUANCE TO THEAPPLICANT.
* Traffic control and public safety shall be in accordance with City regulatk
qns as required by the City Engineer. Every
flagger must be trained as required by (WAQ 296-155-305 and mustfisive certification verifying completion of the
required training in their possession.
* Restoration is to be in accordance with City codes. All street-cut� trench work shall be patched with asphalt or City -
approved material prior to the end of the workday - NO EXCEPTIONS.
+ Three sets of construction drawings of proposed work are required with the permit application.
I HA VE READ THE ABO VE STA TEMENTS AND UNDERSTAND THE PERMIT REQUIREMENTS AND ACKNO WLEDGE
THA T I MUST MAKE THE PINK COPY OF THE PERMIT A VAILABLE ON SITE A T ALL TIMES FOR INSPECTIONS
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or Agent)
CALL DIAL -A -DIG (1-800-424-5555) PRIOR TO BEGINNING WORK
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`UPON COMPLETION OF PERMITTED WORK, AN ENGINEERING FINAL
INSPECTION IS REQUIRED PER CHAPTER 18.00 OF THE EDMONDS
CttLL k14� COMMUNITY DEVELOPMENT CODE.
FINAL' APPROVAL OF PERMITTED WORK.
INSPA16R'S SIGNATURE DATE:_V�_ffi5t.W
For inspection requirements see Engineering Information Handout.