20030042.pdfPermit No: 2'
City of Edmonds
RIGHT-OF-WAY CONSTRUCTION PERMIT Issue Date:
A. Address or Vicinity of Construction:
B. Type of Work (be specific):
�1 i I Contact:
C. Contractor: 1� 1�, f
Mailing Address: 12 2 Phone:
State License #: Liability Insurance:_ Bond: S
D. Building Permit 4 (if applicable). Side Sewer Permit #(if applicable):
E. F� Commercial EJ Subdivision CityProject [:1 EUC(PUD,VERIZON,PSE, AT&T, OVWD)
E] Multi -Family P I Singl e / Family El Other
INSPECTOR:
0 NO G. SIZE OF CUT —X
F. PAVEMENT CUT: YES
CONCRETE CUT: El YES ONO
INDEMNITY. Applicant understands by hisliter signature to this application halshe holds the city qf Edmonds harmless from
injuries, damages or claims of any kind or description whatsoever, foreseen or unforeseen, that may be made against the City of
Edmonds or any ofits departments or employees, including but not limited to M6 defense ofany legal proceedings including defense
costs and attorneyfees by reason ofgranting 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 KILL BE HELD UNTIL� THE FINAL STREET PATCH IS
COMPLETED BYCITYFORCa AT HWICH TIMEA DEBiroR CREDIT HILL REPROCESSED FOR ISSUANCE To THEAPPLICANT.
Traffic control and public safety shall be in accordance with City regulations as required by the City Engineer. Every
Bagger must be trained as required by (WAC) 296-155-305 and must have certification verifying completion of the
required training in their possession.
Restoration is to be in accordance with City codes. All street -cut trench work shall be patched with asphalt or City -
approved material prior to the end of the workday — NO EXCEPTIONS.
Three sets ofconstruction drawings of proposed work are required with the permit application.
CALL DIAL -A -DIG (1-800-424-5555) PRIOR TO BEGINNING WORK
I HA VE READ THE ABOVE STATEMENTS AND UNDERSTAND THE PERMIT REQUIREMENTS AND ACKNOWLEDGE
THA TI MUST MAKE THE PINK COPY OF THE PERMITA VAILABLE ON SITE A TALL TIMES FOR INSPECTIONS
I Date: i W
Signature: .&m
(Contractor or Agent)
M%tjoet�L-
FOR CITY USE ONLY
a �, Right-of-way.Fee:
Approved by:
,
Time Authorized: Void After --
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Disruption Fee/Fund III:
Special Conditions:
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Restoration Fee:
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Total Fee: -
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ReceiptNo: 043
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Issued by: PA ppi I � Ill
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UPON COMPLETION OF PERMITTED WORK, AN ENGINEERING FINAL
INSPECTION IS REQUIRED PER CHAPTER 18.00 OF THE EDMONDS
COMMUNITY DEVELOPMENT CODE (Phole 425-771-0220 Ext. 1326)
DATE:
gNture
FINAL APPROVAL OF PERMITTED WORK: -,444
In ecor
For inspection requirements see Engineering Inspection Information handout.
'SUANCt"
NO WORK SI IALL BE,(; I NPRIORTO illItMITIS
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