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THE SOUTH HALF OF LOTS 369 379 389 39 AND 40, BLOCK 5, THE KELLOGG
PLAT OF EDMONDS, ACCORDING TO THE PLAT THEREOF RECORDED IN VOLUME
2 OF PLATS, PAGE 429 RECORDS OF SNOHOMISH COUNTY, WASHINGTON.
EXCEPT THE EAST 10 FEET OF LOT 36.
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CITY OF EDMONDS
COMMUNITY SERVICES. DEPARTMENT
RIGHT-OF-WAY CONSTRUCTION PERMIT
A. • Owner:
Name
C1C�-
iling AddressCQA,
City State Zip
B. • Contractor:
Permit No.
Issue Date q " 7-6 -qO
Name
Mailing Addres
U-� Or
City State 1 Zip
State License Number Telephone Number
C. • Address or Vicinity of Construction: -71 N nC �-
Type of Work to be Done: (l 7��ru Q `� � !� A�eimask -xi
D. • Work in Connection With: ❑ Sub or Plat [Single Family ❑ City Projects
❑ Commercial ❑ Multifamily
❑ Utility
E. • Pavement -Cut: ❑ Y fQN F. • Size of Cut: t Q X
APPLICANT TO READ AND SIGN
INDEMNITY: Applicant understands and by his signature to this application, agrees tohold 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.
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.
• A 24 hour notice is required for inspection; Please call Engineering:,771-3202
• Work is to be.,inspected during progress and at completion. .
• Restoration'to be in accordance with City Code.
• Street to be'Rept 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 available at the job site for inspection purposes at all times.
Signature: Date:
Owner or Contractor
This Permit Must be Posted at the Job Site For Inspection. Purposes
Call DIAL=A-DIG Prior,to Beginning -Work
APPROVED BY: /%S..I
Time Authorized: Void after,_' � days..
Special Conditions:
PERMIT FEE:
Restoration Feel:
Receipt. No.: [ ��
Fund III Fee:
/� ��cc Street Cut Dimensions: X
RELEASED BY: ��� Date `4a-W (v INSPECTED BY lrl�`' Date
NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE
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FIELD INSPECTION NOTES (Fund III - Route copy to Street Dept.)
Comments:
Diagram:
CONTRACTOR CALLED FOR INSPECTION ❑ YES ❑ NO
Partial Work Inspection by P. W.:
Work Disapproved By: Date:
FINAL APPROVAL BY: Date:
Eng. Div. Jul,
The CRY of Edmonds Side Sewer Drawing EASEMENT NO - ------------
---------------
106-05900 NEW CONSTRUCTION El REPAIRS E] LID NO_ ------------------ - ASMT. NO. - -----------
OWNER -------- HOLLY --- D---S.CE0EMM-CHT --------------------------- CONTRACTOR — .............................. ----------- -------------------------------------- PERMIT NO. --------------------
JOB ADDRESS -------- 7.1.1 ... H&CLOCK --LAY------------------------------------ LEGAL DESCRIPTION: LOT NO. -- ---------------------------- ----- BLOCK NO.
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NAME OF ADDITION .......... ............ ................................
DYE TESTED ON SEWER
Approved:
PWW-OWl-I 1175 (REVA 1/78) DATE ------------------------------------------- - By