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City of Edmonds Permit No: '!5""1"0
RIGHT-OF-WAY CONSTRUCTION PERMIT Issue Date:—
A. Address or Vicinity of Construction:
B. Type of Work (be specific): 7' 'v
C. coras trvxtion co,, ,
Mailing Address:V'U1MKM'1'ma)y'
Edca- wiA 1) 2 0
State License #: f,,50], 32-12 66 5'
City Business License #: tqr,M)C� ", sV7
D. Building Permit#
(,� " ' , r,
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425 771.7270
Liability Insurance: Zc-', Bond: $
Side Sewer Permit # (if applicable):
E. n Commercial E] Subdivision 0 City Project E] EUC (PUD, VERIZON, PSE, COMCAST, 0 VWSD)
El Multi -Family ❑ Single Family 0 Other
INSPECTOR: A
F. PAVEMENT CUT: ❑YES NO G. SIZE OF CUT X
CONCRETE CUT: [_1 YES [;JNO
G. n Mail Approved Permit ❑ Call for Pickup
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 Pecs by reason afgranting 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 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
IHAVE READ THE ABOVE STATEMENTS AND UNDERSTAND THE PERMIT REQUIREMENTS AND ACKNOWLEDGE
THAT I MUST MAKE
THE PINK COPY OF THE PERMIT AVAILABLE ON SITE AT ALL TIMES FOR INSPECTIONS
Signature:
z' Date:
(Cautractor or Agent)
Approvedby:
Time Authorized:V'�cant ,
Special Conditions:
A
C Li"
Al
A"
REQUIRED INSPECTIONS:
3f,joce 5r4z fiaLittl 12A1i,4,,Pi =0 A�� 124LU 4 �� LqOM�n2lff -
f pACall 425-771-0220, Ext. 1326for a 24-hour voice -recorded inspection request line.
F NAL APPROVAL OF PERMITTED WORK: DATE:
I -�r i7m� P A, , Inspector's Signature
O&L avat lip 'K "Ild 4 91,116.,
C\Doc,mmts and SetTings\C,,Mis\My Dots\F,, \E,g—gUROWp—it doc Revised 10/01/03