20070829130534.pdfCity of Edmonds Permit No:
RIGHT-OF-WAY CONSTRUCTION PERMIT Issue Date
A. Address or Vicinity of Construction: 155- a"y'df� „,J
B. Type of Work (be
Mailing Address: lA X l 1 1 ( 1) _
State License #: i A-&6 U ��'4 L -
City Business License #:'" i a
D. Building Permit # (if applicable):
Phone:
Liability Insurance: Bond: $ [ Q J2 0
Side Sewer Permit # (if applicable):
E. Commercial ❑ Subdivision ❑City Project ❑ EUC (PUD, VERIZON, PSE, COMCAST, OVWSD)
❑ Multi -Family ❑ Single Family +_ ❑ Other
INSPECTOR: PXyt f t 7f1 t l)
F. PAVEMENT CUT: ❑ YES ❑ NO G. SIZE OF CUT X
CONCRETE CUT: ❑ YES ❑ NO
G. ❑ Mail Approved Permit ❑ Call for Pickup
"APPLICANT TO READ AND SIGN
INDEMNITY: Applicant understands by his/her signature to this application he/she holds the City of 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 of its departments or employees, including but not limited to the defense of any 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 WILL BE HELD UNTIL THE FINAL STREET PATCH IS
COMPLETED BY CITYFORCES, AT WHICH TIME A DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT:
♦ Traffic control and public safety shall be in accordance with City regulations as required by the City Engineer. Every
dagger 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 of construction drawings of proposed work are required with the permit application.
CALL DIAL -A -DIG (1-800-424-5555) PRIOR TO BEGINNING WORK
I HAVE READ THE ABOY TATEMENTS AND UNDERSTAND THE PERMIT REQUIREMENTS AND ACKNOWLEDGE
THAT I MUST MAKE PINK F THE PERMIT AVAILABLE ON SITE AT ALL TIMES FOR INSPECTIONS
Signature:
(Contractor or Agent)