21800 87TH PL W.PDF111111 lill 1111
15436
21800 87TH PL W
Cit' of Edmonds
y
C.
RIGHT-OF-WAY CONSTRUCTION
-PERMIT
Permit Number.
Issue Date: A,- 'Sr'-
A. Addieis or Vicinity of Constructioh: 218W aith P1 W
10 r AIT-Al :f. I I tz r, I I iA.�: mor 'Tu pt�j Yv 4
117 C. ISC)Q . lype o kLK. spec cj:
/I. of 218, st sw aW 221W . C/I of Mth Ave. W vxf_'vyx,,
2 R'lastiz Main 270'E. Ttu-tri 1 114, Ptzmttc Mtn Wr t4SI!r, r1t nt
Contractor: Ave & cr)dvi)d tc,,
Mailing Aeii' SOOND F21MGV hone: '7425" 356�iS50
. .1.4.99 1.1N, .9w Rvmeftft- 9e203P
State License #: Liability Insurance: Bond: $
D. Building Permit # (if applicable):
Side Sewer Permit # (if applicable):
E. [] Commercial E] Subdivision [I City Project E) Utility (PUD, GTE, WNG, CABLE, WATER)
E] Multi -Family C] Single Family F1 Other
INSPECTOR: INSPECTOR: 14�1 Ll�
F. Pavement or Concrete Cut : 0 Yes IgNo G. Size of Cut: - x H. Chargq�,$
APPLICANT TO READ AND SIGN
INDEMNITY: Applicant understands and by his signature to this application to hold the City of Edmonds harmlessftom injuries, damages, or claims ofany
kind or description whatsoever, foreseen or unforeseen, that may be made against the City of Edmonds, or any C?f its departments or
employees, including or not limited to the defense of any legal proceedings including defense costs and allorneyfees by reason of granting this permit.
THE CONTRA CTOR IS RESPONSIBLE FOR WORKMA NSHIP �4ND MA TERIA IS FOR A PERIOD OF ONE YEA R FdLLO WING THE FINA I INSPEC-
TION 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 PROCESSED FOR ISSUANCE TO THE APPLICANT.
Two sets of construction drawings 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 with City regulations as required by the City Engineer.
All street cut trench work shall be patched with asphalt or City approved material prior to the end of the 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 all timesfor inspection purposes.,
Signature: f �'i
. L "" 4,1u.") - --. ) - ----Date.-
(Contractor or'Agent) J (J
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY.
HT OF::,W FEE�
TIME AUTHORIZED: VOID AFTER L40V, 1641 DAYS, DISRUPTION MeTUND I I t:
SPECIAL CONDITIONS:
4- 41,�,i'�
P'o ey M"A/1411 �W+ �'g
RFSTORATION FEE:
OTAL FE1,
RECEIPT NO,: "I
ISSUED BY:;
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE Eng. Di� 1997
FIELD INSPECTION NOTES
Comments:
Diagram.:
(Fund 111 - Route copy to Street Dept.)
CONTRACTOR CALLED FOR INSPECTION El YES 1:1 NO
Partial Work Inspection by P.W.:
Work Disapproved By: Date:
FINAL APPROVAL BY: Date:
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--------- : -------------- NOTES --------------------------------
1. CALL 2 DAYS BEFORE YOU DIG 1-800-424-5555
2. PROJECT MANAGER: DOUG USITALO - 425-356-7520
SCALE: 1"r,4V(
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Notes: The City of Edmonds
1) Field locate all utilities.
Call 1-800-424-5555
24 hours before digging.
2) Survey is not required
3) Maintain a minimum of 5'
horizontal and 3' vertical
clearance from all city
utilities and appurtenances.
4) Cuts in paving are shown as S
5) bla --cuts in paving anticipated.
No.
DESCRW11ON
DATE
BY
APPO
REWSIONS
AS WILT INFORMATION
FrTTER OR CONTRACTOR:
COOROWATOR:
F
DATE COMPLETED:
PERCENT COMPLETED.
E
L
TEST
INSTALLATIONIRETIREMENT
SUMWRY
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PRESSLIRE:
MAM SUE
M0kTERtAL
TOTAL FOOTAGE
DATE ON:
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DATE OFF*
TIME OFF,
TYPE OF PIPE:
PIPE MANU FACTLIRER:
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ENEFCY
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