120 4TH AVE S.PDFi 1111111111111114656i
120 4TH AVE S
STREET�FILE
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CITY OF EDMONDS
PUBLIC WORKS DEPARTMENT
RIGHT - OF - WAY CONSTRUCTION PERMIT
Permit No. " z 2 -
STREESTREET
T FILEUe Date —12-11 / 7 1
A.
62 -
A. •Addressr°r vicipy of Construction Ic20 -5-M A —'
• Owner:
Name 1
Mailing Address
City, State, Zip Code
• Permit Issued To:
&peof Work to be Done: -L.
i
• Work in Conn ion With: t J
1�
❑. Sub or Plat 11 Single Family
[� Comml. / Ind. ❑ Apt. Condo.
• Pavement Cut: ❑ Yes ❑ No
• Contractor: � `�� �`�' �`� � �' � � S-..5
r .
Name
q co
Mailing Address �g �j State License Ny^J(umber
4 ,, [y
City, S.N
State, — Zip Code Telephone Number
* * NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE * *
B. APPLICANT TO READ AND SIGN
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, foreseen or unforeseen, 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.
Upon issuance of this permit, the contractor is responsible for workmanship and materials for a period of one year
following the final inspection and acceptance of the restoration by the Engineering Division.
Funds held from the Security Deposit (estimated restoration fee) will be held until the final street patch is completed, at
which time a debit or credit will be processed for issuance to the applicant.
Work is to be inspected. Restoration to be in accordance with City Code. Traffic Control to be in accordance with Traffic
Section of City Code. Street to be kept clean at all times. A 24 - hour notice is required for inspection by Engineering.
Call 775-2525, extension 220.
I understand that this permit must be available at the job site for inspection purposes at all times.
Signature-'_`. - y -r Date
Owner or Agent
* * THIS PERMIT MUST BE POSTED AT THE JOB SITE FOR INSPECTION PURPOSES
CALL DIAL - DIG PRIOR TO BEGINNING WORK
C. Issued By:
Time Authorized: Void after ,"7 days
Special Conditions:
Ammendments:
Permit Fee:
:3c .aa
Security Deposit:
Receipt No.:
Fund 111 Fee:
Street Cut Dimensions
X
,k * NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE
Eng. Div. December 1978
FIELD INSPECTION NOTES (Fund 111 - Route cony to Street Dent.
Comments:
Diagram:
Contractor called for inspection Yes No
Nork Disapproved By: _ nate: Bv: nate:
Work Approved By: ___ � _Date:
Inspector:
Ena. Div. December 1978