521 FORSYTH LN.PDFiiiiii iiiiiiii
13992
521 FORSYTH LN
STREET FILE 0
CITY OF EDMONDS, PLANNING DEPART11ENT
505 BELL STPEFT
EDMONDS, WA .98020
775-2525
Name of Applicant: / tl�
Mailing Address:
APPLICATION FOR STREET USE PERMIT
co,R;>
Telephone Number:_Wq - 2-712 Date:- )ZI "1 /0
Description of Public Place or Portion thereof desired to be used: (exhibit may be
attached)
(f-XH/)3/7_ /'F/T,4c/�,-_D
Type of Use desired to be made of Public Place: _�_05 _1x'1.461< 4ceA�C'D ?4 j��11-16-
S7R/T_� + -T6-mP CLOSC-'t� OF Sla-W+til ag1r4(,_
I
If applicable, attach plans and specifications for any utility or structure to be erected
and/or maintained on the Public Place:
TEMPORARY PERMIT: Unless otherwise designated herein, this permit is,understood by
applicant to be wholly of a temporary nature, that it vests no permanent right whatsoever.',
If the permitted use becomes dangerous or such structure shall become insecure or unsafe,'
or shall not be constructed, maintained or used in accordance with the provisions of this
title, the same may be revoked and the structureand obstructions ordered removed by order
of the City Engineer. If,th* agplica_tion is for a s ifie period of time, the terms
/'t 3 /V
.Zo>,_ '�7/ q / 43
of said application is: �/q '4 �4
INDEMNITY: Applicant understands and by his signature to this application, agrees to hold
the City of Edmonds harmless from any injuries, damages or claims of any kind or descrip-
tion whatsoever, foreseen or unforeseen, that may be made against the applicant or 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, court costs, and attorney fees by reason
of granting this permit ' In addi*tion, applicant understands that the City shall b6 provided
a certificate of insurance to indemnify and hold the City of Edmonds harmless from all
clainis and/or property damage, naming the City of Edmonds as an also insured.
APPLICATION OF CHAPTER 6.40 OF THE EDMONDS CITY CODE: Applicant
or had the oF-portunity to read, Chapter 6 40 of 0e-Edmonds City
and understands that all terms of that Or�inance are incorporated
in full and this application and permit,therefore are subject to
f fk cri 4 r + r A
V I- "IV " a J V U.
Ap�icant's Signature
//24/0.3
Da te-
warrants that he has read,
Code, attached herewith,
h * erein.' As if set forth
the terms of that Chapter
11/7/74 rev.
City of Edmo . nds Plantnng Department
I MIT -- Pa2e 2.
APPLICATION FOR STREET USE PER __
Approval (and Agreements if applicable) of Abutting Property Owners:
Sionature Printed Name Address Date
DO NOT WRITE BELOW THIS LINE (To be completed by Issuing A .. gency)
city Council Approval (Attach Minute Entry):
due January 1, 19
Permit Fee: Annual Fee:
Amenities Design Board Approval (if applicable) Attach Minute Entry:________—.
Building Official Approval (if applicable): —Signature 7a t —el
Provision for Indemnity:
Terms and Provision of Perforniance Bond, if applicable: (Reference.6.40.050 of applicabl
Ordinance)
112-
PERMIT AUTHORIZATION BY i g nuaAt u �r-e—G—A—a Date
PERMIT NO. DATE
Remarks: p?
0.5 )p I UG.
11/7/74 rev.
)REss OF AGENCY
R wi wtlr�l MARTIN & LEWIS, INC.
ijo Columbia Street
Seattle, Washington 98104
(206) 623-4920
iiAME AND ADDRESS OF INSURED
PUGET WEST CORPORATION
P.O. Box 669
Edmonds, Washington 98020
.1 1 COMPANIES AFFORDING COVERAGES
IIIIPAN
LET-rER ' AUNITED PACIFIC INSURANCE COMPANY
COMPANY Q
LETTER LJ
COMPANY
LETTER C
COMPANY
LF.nER D
COMPANY
LETTER E
This is to cerlify that policies of insurance listed below have been issued to the insured named above and are in force at this time. Notwithstanding any requirement, term or condition
of any contract or other document with respect to which this certificate may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the
terms. exclusions and conditions of such Dolicies. I
Limits of Liability
in Thousands
(000)
COMPANY
LETTER
TYPE OF INSURANCE
POLICY NUMBER
POLICY
EXPIRATION DATE
EACH
AGGREGATE
OCCURRENCE
GENERAL LIABILITY
BODILY INJURY
$
$
A
]a COMPREHENSIVE FORM
id PRE MIS ES—OPERAT IONS
PROPERTY DAMAGE
$
$
EEXPLOSION AND COLLAPSE
HAZARD
UNDERGROUND HAZARD
PRODUCTS/COMPLETED
OPERATIONS HAZARD
BODILY INJURY AND
CONTRACTUAL INSURANCE
LP 4 84 78 54
4-26-83
PROPERTY DAMAGE
s 500
s 550
BROAD FORM PROPERTY
COMBINED
DAMAGE
INDEPENDENT CONTRACTORS
I
PERSONAL INJURY
PERSONAL INJURY
s 500
AUTOMOBILE LIABILITY
BODILY INJURY
(EACH PERSON)
$
COMPREHENSIVE FORM
BODILY INJURY
$
E] OWNED
(EACH ACCIDENT)
1:1 HIRED
PROPERTY DAMAGE
$
E]
BODILY INJURY AND
NON-OWNFO
$
PROPERI Y DAMAGE
COMBINED
EXCESS LIABILITY
F] UMBRELLA FORM
BODILY INJURY AND
PROPERTY DAMAGE
$
$
OTHER THAN UMBRELLA
FORM
COMBINED
WORK ERS'COM PE NSAT ION
STATUTORY
and
EMPLOYERS' LIABILITY
$ (EACH ACCIDENT)
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES
Applies to job shack at 521 Forsyth Lane, Edmonds, Washington.
It is understood and agreed that the City of Edmonds is named as additional insured
and held harmless from all claims and/or property damage as pertains to the named permit.
Cancellation: Should any of the above de "ribpolicies be cancelled before the expiration date thereof, the issuing com-
pany will endeavor to mail ays written notice to the below named certificate holder, but failure to
e no bb il
mail such notice shall impose no bb igation or liability of any kind upon the company.
Notice of Cancellation to be sent by certified mail.
NAME AND ADDRESS OF CERTIFICATE HOLDER:
DATE ISSUED:
F�
City of Edmonds @
Edmonds, Washington 980
JAN 2 0 ".
AUTHORIZQQ REPRES
ter E. Breve, CPCU
ACORD 25 (1-79)
I
L��WL DESCRIP71ON
ALL THAT PORTION OP- THE WE
QUAP-TER OF- THE NORTHWE5T
-T-OWNSHIP 27 NORTH,. R4NGE 3
P-OLLOWS:
BEGINN!NG 145.50 P-EE7 aAS-r-,
THE NORTHWEST CORNER OP, cz
SOUTHWE5-F QUAPTEP- OP- -rHI
THENCE SOUTH aOO P-EET- i. T
THENCE. NOR-T-H 300 P-EET I
CCUNT�/ ROAD 123 F-EE7- TO
EXCEPT -FHE SOUTH 25 P7EE-
O�:- EDMONDS UNDER AUDITO�
RSYTH LANE 703 TRA/tc-� I- OCAT1014
2? 3 - 0
199^ -9e, 09 E
To s //-,X WAU� cu;et3
C-U776� ..PLAT'01
F
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c /A No.
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E 01
-m7
AADE By ME OR
3UMEMENTS OF
IARC) SL','E---
S'
RICHAR'
IN SW 1/4 OF NW 1/4 OF Si
SNOHOMISH COUNTY,
L lo v e S a i
s
SURVEYORS�
23106 100THAVE.
DRAWN CHECKED DArE
N GWL 11-19-81