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City of. Edmonds
RIGHT-OF-WAY CONSTRUCTION
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PERMIT Permit Number. " o{
Issue Date: 7
A. Address or Vicinity of Construction: 714 Fir St `X 9425964
B. Type of Work (be specific): Install New Service
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C. Contractor: Washington Natural Gas Company' Contact: Frank Swan
Mailing Address: 815 Mercer Streer, Seattle Phone: 224-2278
State License #: WA 98111 Liability Insurance: Bond: $
D. Building'Permit # (if applicable): Side Sewer Permit # (if applicable):
E. ❑ Commercial ❑ Subdivision ❑ City Project ® Utility (PUD, GTE, WNG, CABLE, WATER)
❑ Multi -Family ❑ Single Family ❑ Other
INSPECTOR: INSPECTOR: 47�4
F. Pavement or Concrete Cut: ❑ Yes No G. Size of Cut: x) H. Charge $
A PLI NT TO READ AND S GN
essl"rd!Y �
INDEMNITY. Applicant understands and by his signature to this application, agrees to hot-h�City of Edmonds harmltnj� a, damages, or
claims of any kind or description whatsoever, foreseen or unforeseen, that may be made ag' ain)t 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 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, � FOR ISSUANCE TO JE .�qLI�A !rT
Construction drawing 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 witlEit3tlregulations as required bhe y F�(1gneer.
All street cut ditches shall be patched with asphalt or City approved material prior to the end-Cit
of thb 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 al/l s or ins e ion purposes.
Signature: J'K Date: 08-12-1994
(Contractor or Agent)
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY: IAA4-I V ' / / R`
TIME AUTHORIZED: VOID AFTER ` ��`� DAYS
SPECIAL CONDITIONS: Ahk
COMMENTS:
RIGHT OF WAY DEPOSIT
DISRUPTION FEE/FUND 111:
RESTORATION FEE:
PERMIT FEE: 30.
TOTAL FEE:
RECEIPT FEE:.
DATE:
ISSUED BY:
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
En&7g. I)iv. 1991
'•J
FIELD INSPECTION NOTES
Comments•
Diagram
(Fund 111 - Route copy to Street Dept.)
CONTRACTOR CALLED FOR INSPECTION ❑ YES
Partial Work Inspection by P.W.:
Work Disapproved By: Date:
FINAL APPROVAL BY: Date:
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., Add*' dum to.s. city of Edmonds_
' Per it ` ppICA!,on
.,.r........_._._ . Submitted bys pzTcHnL $O 'TANKFo
Snginsering �l d "
Washington Natural -Gas
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gas main
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-ss- sewer
$ water hydrant
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