124 3RD AVE N.PDF11111111111111
14601
124 3RD AVE N
• STREET USE PERMIT APPLICATION
NAME OF APPLICANT: .SGO TT r L 6t/R.r'
NAME OF BUSINESS: 6PM'0 00" JFFLEk Ry �^/ltJZttLn� a .1NC
MAILING ADDRESS: 'p. a ' gOfi 60.01
CONTACT PERSON AND PHONE
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ADDRESS OF PUBLIC USE: i4u,-oY 0oT ,1,efN- A&IP 00"- 44sT o-' r#IAP kR. Al•
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Describe th�ublic,,place or portion of public space to be utilized:
°` A �l�d���f •
Specify the type;,•of-use desired: Wf Wd
w/L
tNrEo-s,&rxvA1 of mo At -toy 4-e-10 8" , s ?.
Specify the length of time for use: ZkOm 04C /49 �
NOTE: The issuance of this permit is understood by the applicant to be of a temporary nature and that no vested right is granted.
INDEMNITY.• The applicant understands and by his/her 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 applicant or the City of Edmonds, or any of its departments or employees, including but not limited to the defense or
any legal proceedings including defense costs, court costs, and attorney fees by reason of granting this permit. In addition, the
application understands that the City shall be provided 'a CdMfleate of Insurance to, indemnity and 3hold harmless -the City of
Edmonds from all claims and/or property damage, and naming the City of Edmonds as an additional insured.
CODE APPLICATION: By signing the application below the applicant warrants that s/he has read or had the opportunity to read
Chapter 18 of the Edmonds Community Development Code and s/he understands that all terms of the adopted ordinance are
incorporated herein as if set forth in full and this application and permits therefore are subject to the terms of that Chapter.
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STREET FILE
Struseho.docj1g6/98
SIGNATURE OF APPROVAL FROM ABUTTING PROPERTY OWNERS
When applicable, if the street use proposal directly impacts any adjacent business or private property owner •
the applicant must obtain written approval from the affected parties: Note, this requirement is evaluated by
City Staff and, when required, the applicant will be notified.`'
Signature :, -Address
Signature Address
Signature Address
Signature {, ; f i 1 Address
DO NOT WRITE BELOW THIS LINE --FOR CITY USE ONLY
Planning Division Approved By' �' ``' /f�'`s ADB# :Date'
j •,
Public Wol 9 ADDroved By Date IZ-11-fkS
erit`AiroFire Dartrrved DateI2Ivilce Police Department Approved By Date' 2'''/ �'`` ., •
Certificate of Insurance Verified By . Date
Engineering Division Approved By s e e `��"" "` ea d Date
2'
J.sMAy
Remarks or Comments: Trw c,k rou tt l w+ws t be S06*617e j 4t,%d o. rrru+�e
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STREET USE PERMIT#
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DATE OF ISSUANCE
12-/ f 1l 99
RELEASED BY RECEIPT# IZ(OlQJ
BUILDING PERMIT #�
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DATE (MMIDD"
12 10 98
.PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
PETERSHAGEN INSURANCE
1 WALL STREET
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
RETT WA 98201
COMPANIES AFFORDING COVERAGE
-
COMPANY 1
A COLONY INSURANCE ' C0 .'
INSURED I
COMPANY - -
CAMPBELL'-& FLEURY CONSTRUCTION
B
INC_ —& FAMILY FLEURY LLC
COMPANY -
PO BOX 6005
C
EDMONDS WA 98026
COMPANY
D
COVERAWS
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED
BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, 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 POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Co
LTA
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MMIDD"
POLICY EXPIRATION
DATE (MMOD"
LIMITS
GENERAL
LIABLrY
GENERAL AGGREGATE
s2,000,000
A
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE 7 OCCUR
GL 13 2 5 2 0 3
0 2/ 2 2/ 9 8
0 2/ 2 2/ 9 9
PRODUCTS - COMPIOP AGG
s2,000,000
PERSONAL & ADV INJURY
s 1 0 0 0 0 0 0
EACH OCCURRENCE
$1 r 0 0 0 0 0 0
A
OWNER'S & CONTRACTOR'S PROT
FIRE DAMAGE (Any one fire)
$5 0 0 0 0
MED EXP (Any one person)
$1 0 0 0
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
$
BODILY INJURY
(Per person)
$
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS -
I r
- -
BODILY INJURY
(Per accident)
$
_- -
PROPERTY DAMAGE
$
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
OTHER THAN AUTO ONLY
ANY AUTO
EACH ACCIDENT
$
AGGREGATE
$
EXCESS LIABILITY
EACH OCCURRENCE
$
AGGREGATE
$
UMBRELLA FORM
$
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
WC STATU- OTH
TRY LIM ER
'
EL EACH ACCIDENT --
$
THE PROPRIETOR/ INCL
PARTNERSEXECUTIVE
FlEXCL
EL DISEASE - POLICY LIMB
$
EL DISEASE - EA EMPLOYEE
s
OFFICERS ARE:
OTHER
DESCRIPTION OF OPERATIONSLOCATIONSNEHICL SISPECIAL ITEMS
IT IS AGREED AND UNDERSTOOD THAT THE CITY OF EDMONDS IS NAMED AS AN
ADDITIONAL INSURED.
CERTIFICATE HOLDEq...::<' '... .....:
CANC�LU1�it
ATTN : V I V IAN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
CITY OF EDMONDS
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
U I LD I NG DIVISION
3-a— DAYS wRIT1EN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
121 5TH AVE N
BUT FAILURE TO MAL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
EDMOND S , WA 98020
OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
rlROR REPRESENTATIVE
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