COL-76th-ROW app.pdfCity of Edmonds Permit No: t✓ ys 1 zo
RIGHT -GF -WAY CONSTRUCTION PERMIT issue Rale:
A. Addressor Vicinity of Consirucuon:7GTFI AV V
n, Tyin of Work (6 --specific), POTHOLE MSTING UTTLITIFS WITH VACUUM TRUCK
C. Contractor: PILCHUCR CONTRACTORS, INCConlact: MARVIN LARUE
Maihag Addoc= PO BOX 2579 — 579Phone: 206-619--8418
WA
State License #: PIL CI UIN& Liability Tnsurancc: - Bond: S
CiryBusiness License # _NR -014936
U. Ouilding Pennir # (ifapplicable): Side Sewer Permit # (if applicable):
E. ❑ Commercial ❑ Subdivision ❑ City Project ❑ EUC (PUB. VERIZON, PSE, COMCAST. OVWSD)
❑ Multi -Family D Single Farnily [Z Other
INSPECTOR:
P. PAVFMENTCUT. [4YFS ONO G. SIZE OF CVT X
CONCRETECUT: ❑VFS ONO 12IAMETER CORE
G. ❑ Mail Approved Permit ' CK Cal I for Pickup
e
INDEMNITY: Applicant nnd0jsmn& hr his/her signature to this application hrlshe holds the CIO, of Edmonds harmless firam
injuries, damages or claims of any kind ur deseriprion wharsoever, foreseen oe unforeseen, that may he made against the City of
Edmonds or any of irs departments or employees, including bur nor limiled to the defuse afany legel proceedings including defense
costs and atiorneyfoes by reason of gronting this primer.
TILE CONTRACTOR IS RESPONSIBLE FOR WDRRMANSHIP AND NATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING TRE FWAL
INSPECTION AND .4CCMITANCE OF TUE WORX ESTIMATED R£SrORATION FEES WILL BE HELD UNTIL THE FINAL STREET FdrCN RS
COMPLETED BY CITY FORCES, Ar WHICH T1ME4 DEBrr OR CREDIT WILL li£ PROCESSED FOR ISSUANCE TO THE APPLICANT.
s Tralliie control and public safety shall be in aceardanct with City regulations as required by the City Engineer. Every
flogger must be traloed as required by (WAC) 295.155.3D5 and must bave etrtification verifying completion of the
required training In their possession.
a Restoration is to be in accordance with City codes. All street -cul trench work shall be patched with asphalt or City -
approved material prior to the end of the workday -NO EXCEPnONS.
e Three sets of construction drawings ofproposed work are required with the permit application.
CALL DIAL -A -DIG (1-800.424-5555) PRION TO BEGINNING WORK
I HAVE READ THE ABOVE STATZMENTS AND UNDERSTAND THE PERMIT REQUIREMENTS AND ACItNOWLEDGE
THA TIMUSTM WE PINK COPY OfTNEPERMITAVAI,LASLh'ONSI7EATALLTIME,SFO1RINSPEC77ONS
Slgnarura; 4- — Date;_ f�I I
FOR CITY USE ONLY
Approved by: Right-of-way Fee:
Time Authorized.- Void After I / Disruption FeelFund 111:
Special Conditions: Inspection Fee:
Total Fee:
Receipt No:
Issued by: --
REQUIRED INSPECTIONS:
Call 425-771-0220, ExL 1326 for a 14 -hour voice -recorded impection request Iirre.
FINAL APPROVAL OF PERMITTED WORK: DATE:
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