22302 76TH AVE WIIIIIIIIIIIIII
15127
22302 76TH AVE W
City Of Edmonds Permit No: �U
RIGHT-OF-WAY CONSTRUCTION PERMIT -Issue Date:
A. Address or Vicinity of Construction:yz-,302. 1(.,T 1wo V
B. Type of Work (be specific): UTI LI f l �S C�-( �l . , %�j11/I►JG
t Q oCe r
4-C. Contractor: 0 0 Vt L �� GtK �j Contact: 11c�r1 �'1 t
l „,oydzs �,S- -1�
Mailing Address: 'q�2 Fm h1Ujp Phone:
State License #: S 0!AvyJVkc0 ri W Liability Insurance: Bond: $0 k
D. Building Permit #.(if applicable): Side Sewer Permit #. (if applicable):
E. ❑ Commercial
❑ Multi -Family
INSPECTOR: N
❑ Subdivision
❑-Sing)e Family
❑ CityProject ❑ EUC (PUD, VERIZON, PSE, AT& T, OVWD)
❑ Other
F. PAVEMENT CUT: .X YES ❑ NO G. SIZE OF CUT X
CONCRETE CUT: ❑ YES ❑ NO
Al"I'LICANT TO IZEAD 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 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) 206-155-305 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 UNDERSTAND THE PERMIT REQUIREMENTS AND ACKNOWLEDGE
THAT I MUST MAKE THE PINK CO
OF THE PERMIT AVAILABLE ON SITE AT ALL TIMES FOR INSPECTIONS
`HSignature:
or Agent)
FOR CITY USE ONLY
Approved by: Ali
Time Authorized.: Void After M
Special Conditions: '"�l2P�'!'�t oP�tJ� -rrai
�Tiw Si w'G-�i ' ��'1� �•1�Mti?� �Ur� � � ' •
Date: ' Z O I
Right-of-way Fee:, 160 ft a
Disruption Fee/Fund 111:* 0a
Restorati n Fee:
An
Total Fee SS
Receipt No: 0
Issued by:
.S'?61T - DI#AD nJtU rt-"L i2K/Z ^_Aii10 7 443bAS -- /096
UPON COMPLETION OF PERMITTED WORK, AN ENGINEERING FINAL
INSPECTION IS REQUIRED PER CHAPT 8. OF THE EDMONDS
COMMUNITY DEVELOPMENT CO P -7 - 20, Ext. 1326
FINAL APPROVAL OFPERMITTED WORK: - DATE: Lo
41 CV toam-- o KWdJCK_
For inspection requirements see Enj
's Signature
Inspection Information handout.
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE