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'CrT? OF EDMONDS Permit No.__s 41
COMMUNITY SERVICES DEPARTMENT sue Date
RIGHT-OF-WAY CONSTRUCTION PERMIT TREET FILE
A. 0 Owner: B. e Contractor:
Name
Mailing Address
R R�C� Z C)
city State Zip
! J / " , / - 11 1
9 Address or Vicinity of Co
,�structjoyn-_/ta_Q
Type of Work to be Done�",72\
Work in Connection With: El Sub or Plat
0 Commercial
Pavement Cut: El Y ><N'
APPLICANT TO READ AND SIGN
Name
Mailing Address
City State Zip
State License Number
11 Single Family
0 Multifamily
Telephone Number
11 City Projects
y utility C_
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 description whatsoever, forseen or unforseen, 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, court costs, and attorney fees by reason of granting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE
YEAR FOLLOWING THE FINAL INSPECTION AND ACCEPTANCE OF THE WORK.
Funds held from the Security Deposit (esti)nated restoration fee) will be held until the final street patch is completed
I
by City forces, at which time a,., ot�kfeaitAvill be processed for issuance to the applicant.
• A 24 hour notice is required for inspection; Please call Public Works: 771-3202
• Work is to be inspected during progress and at completion.
• Restoration to be in accordance with City Code.
• Street to be kept clean at all times.
• Traffic Control to be in accordance with City regulations.
• All street -cut ditches must be patched with asphalt or City approved material prior to end of working day;
no exceptions.
I understand the above and that this permit must be ayailable at the job site for inspection purposes at all times.
Date: P) 'N
Signature. U -
Own& or Contracto\r
This Permit Must Be Posted at the Job Site For Inspection Purposes
Call DIAL -DIG Prior To Beginning Work
ISSUED BY:
Time Authorized: Void after f 00 days.
Special Conditions:
Amendments: —
PERMIT FEE: -
Security Deposit:
Receipt No.: —
Fund I I I Fee: —
Street Cut Dimensions:
X
NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE
Eng. Div. July 1985
FIELD INSPECTION NOTES
(Fund I I I - Route copy to Street Depf.)
Comments:
Diagram:
CONTRACTOR CALLED FOR INSPECTION 0 YES 0 NO
Partial Work Inspection by P. W.:
Work Disapproved By:
FINAL APPROVAL BY:
Date:
Date:
Eng. Div. July 1985