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TAX ACCOUNT/PARCEL
BUILDING PERMIT (NEVG
COVENANTS(RECORDED)FOR:
CRITICAL AREAS: DETERMINATION: ❑ Conditional Waiver ❑ Study Required ❑ Waiver
DISCRETIONARY PERMIT #'S:
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
PERMITS (OTHER):
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED:
SEWER LID FEE $: LID
SHORT PLAT FILE: LOT: BLOCK:
SIDE SEWER AS BUILT DATED:
SIDE SEWER PERMIT(S) #:
SOILS REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
FOR:
METERWATER
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LATEMP\DSTs\Forms\Sftet File Checklist.doc
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City of Edinons
j RIGHT-OF-WAY CONSTRUCTION
PERMIT Pe
rmit Number:
4
Issge Date:
A. Addressor Vicinity of Construction:
o
18 99 B. Type of Work (be specific): /% U-1 , b,' - ('
p-1
C. Contractor: OLYM lWContact:
Mailing Address: % C i Phone: %%4- 77�
State License #: _ Liability Insurance: Bond: $
D. Building Permit # (if applicable):
Side Sewer Permit 11(if applicable):
E. ❑ Commercial ❑ Subdivision ❑ City Project Utility (PUD, GTE, WNG, CABLE, . ATER)
❑ Multi -Family ❑ Single Family ❑ Other
INSPECTOR: INSPECTOR: I'J
F. Pavement or Concrete Cut : 9Yes ❑No G. Size of Cut: x H. Charge $
APPLICANT TO READ ANI))lSYGN f(}}crh
INDEMNITY: Applicant understands and by his signature to this application, agrees to hold the city of Edmondg 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 or 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.
Construction drawing 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 ditches shall be patched with asphalt or City approved material prior to the end of the working day;
NO EXCEPTIONS.
Ihave read t e above statements understand the permit requirements and the pink copy of thepermit will be
available on ite at a imes ,or insyOgnTeepurposes.
Signature: Date:
(Contractor o-r Agen
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY: 21"� RIGHT OF WAY DEPOSIT
TIME AUTHORIZED: VOID. -AFTER - Z.0 -DAYS. DISRUPTION FEE/FUND Ill:
SPECIAL CONDITIONS: JJ' f RESTORATION. FEE:
PERMIT FEE:" 5l% oo
TOTAL FEE:
COMMENTS: RECEIPT FEE:
DATE: ISSUED, BY:---6tVk!-�/1=�•�
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Eng. Div. 1994
I
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NOTICE:
No warranty of accuracy.
The information shown on the attached map(s)
was compiled for use by the City of Edmonds,
its Employees and Consultants. The City of
Edmonds does not warrant the accuracy of
anything set forth on these map(s). Any person
or entity requesting a copy should conduct an
independent inquiry regarding the information
shown on the map(s), including, but not limited
to, the location of any sewer stub shown. Such
sewer stubs may or may not exist and may or
may not exist at the location shown. Neither
the City of Edmonds nor its employees or
officers shall be liable for the information given
on map(s), nor for any one representation
provided based upon said map(s).