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r. i City of 'Edmonds Permit No:-03,�oZ,,
RIGHT-OF—WAY CONSTRUCTION PERMIT Issue Date: /,-;�'
a n ll ' \
A. Address or Vicinity of Construction: `�►.� C)0 c � I � q L ,S L.
B. Type of Work (be specific) \'15�rc^ AJ-, Zo AVA(3 a
4191 b SF5 %CMG Ei C12�
C. Contractor: �1, l-R 1 C i G ,\ = Contact: C)L
Ma fling Address: ULU lJ Phone: G (o " JY �/ 13
W
State License #: `io, 0_ 1 C)l 111 A Liability Insurance: f, Bond: $
D. Building Permit # (if applicable): F '` Side Sewer Permit # (if applicable):
E. ❑ Commercial ❑ Subdivision" ❑City Project ❑ EUC (PUD, VERIZON, PSE, AT& T, OVWD)
❑ Multi -Family r ❑ , SingleFamily ❑ Other
.., / ,.,. / r.': p"�b,n...i.•,t �, lr+L 1-.•. r.•_.,,l,�r �',.r�`r f�7 ..
INSPECTOR:
F. PAVEMENT CUT: ❑ YES 2-N60 _G. SIZE OF CUT Q X
CONCRETE CUT: ❑ YES ❑ NO
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 arty legal proceedings including defense
costs and -attorney fees by reason of granting 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 CITY FORCES, 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
flagger 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 ABOVE STATEMENTS AND UNDER' AD THE PERMIT REQUIREMENTS AND ACKNOWLEDGE
THAT I MUST MAKE THE PINK, COPY OF THE PERMIT A VAILABLE ON SITE AT ALL TIMES FOR INSPECTIONS
Signature:
(Contractor or Agent)
Date: l 0 �o� Cl Lo 3
FOR CITY USE ONL '
Approved by:)0�_I � t Ii Right-of-way Fee: Az foo;x
Time Authorized f Void After004 Disruption Fee/Fund 111:
Special Conditions: 4'_'T0 A RC W to' / i'S og. GW — Restoration Fee:
NA1 AMT,,11 8F'7rr=42 CnN1>1r10N. 10An,_ lNTotal Fee: ,A275.G�
e.FPAt 41,#Qrn-. PfZi),tt Atr etry np, 6_()A4t'3NDS Receipt No:
t �y-i t I T I Dfl ,u n r r-Ca 1,C F P/--bt= STR l AMS Issued by.,
INCS, PFC7-1nAL 441 Kt M[.IM W %-2x1h'F:1L (_nr,�i?2[�G �✓` rlN4L 't� 6C:�LrA
UPON COMPLETION OF PERMITTED WORK, AN ENGINEERING FINAL
INSPECTION IS REQUIRED PER CHAPTER 18.00 OF THE EDMONDS
COMMUNITY DEVELOPMENT CODE,(Phone 425-771-0220, Ext. 1326)
FINAL APPROVAL OFPERMITTED WORK. . DATE:
Inspector's Srgn ture
For inspection requirements see Engineering Inspection Information handout.
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCI?