219 3RD AVE N.PDF219 3RD AVE N
CITY OF EDMONDS Permit No.
PUBLIC WORKS DEPARTMENT STHH ET FILE Issue Date 7
i
RIGHT - OF - WAY CONSTRUCTION PERMIT
A. *Address or vicinity of Construction
• Owner: /.� �v'l< I�tAtir1..
Name
Mailing Address
P_ 4.14 o A,-h �✓ . 9 �a z c
City, State, Zip Code
• Contractor:' f i< e i l
rName
d .'`•�"!�'�" '
� r
Mailin Address
City, State, Zip Code
• Permit Issued To:
• Type'of Work to be Done:
• Work in Connection Wa
❑ Sub or Plat
❑ Comml. / Ind. ❑
• Pavement Cut: ❑
State License Number
`7 ily- C/662
Telephone Number
Single Family
Apt. Condo.
Yes X No
* * NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE * *
B. APPLICANT TO READ AND SIGN
INDEMNITY: Applicant understands and by his signature to this application, agrees to hold the City of Edmonds harmless
from any 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, court costs, and attorney fees by reason of granting this permit.
Upon issuance of this permit, the contractor is responsible for workmanship and materials for a period of one year
following the final inspection and acceptance of the restoration by the Engineering Division.
Funds held from the Security Deposit (estimated restoration fee) will be held until the final street patch is completed, at
which time a debit or credit will be processed for issuance to the applicant.
Work is to be inspected. Restoration to be in accordance with City Code. Traffic Control to be in accordance with Traffic
Section of City Code. Street to be kept clean at all times. A 24 - hour notice is required for inspection by Engineering.
Call 775-2525, extension 220.
I understand that this permit must -,be available at the job site for inspection purposes at all times.
Signature: �� p-�--- Date
Owner or Age, npy—�
1t THIS PERMIT MUST BE POSTED AT THE JOB SITE FOR INSPECTION PURPOSES
CALL DIAL - DIG PRIOR TO BEGINNING WORK
Time Authorized: Void after S days
Special Conditions:
Ammendments:
Permit Fee: 11da tip% ["h!
Security Deposit:
Receipt No.:
Fund III Fee:
Street Cut Dimensions
X =
* * NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE * *
Eng. Div. December 1978
FIELD INSPECTION NOTES
(Fund. 111 - Route cony to Street Dept.
Comments:
Diagram:
Contractor called for
*.Mork Disapproved By:
Work .Approved By:
Inspector:
inspection
Yes No
Pate: Bv: Date:
Date:
E
ni
1978