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PROJECT NAME- We,
,t gofe � (4 b -tnice&Pa
CONTRACTOR: SAo Ov ()
Mailing Address: PO RoY 110-7
State License #:
City Business License th
ROW PERMIT NO.: ENG
ISSUE DATE:
CONTACT: -rrevvr Vlelv,'560
Phone #: 4 79
Fax 4::
Email #:
El Liability Insurance F-1 Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: nwA a3 Way
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F-1 Commercial El Subdivision City Project
M' Traffic Control (Only)
F-1' Multi -Family F-1 Single Family D Other
0 EUC (PUD, VERIZON, PSE,
CONICAST, OVWSD):
Is this permit part of a blanket permit? ❑ Yes 0 No
I ANY ASSOCIATED PERMITS? Bi D# ENG#
DESCRIPTION OFPROPOSED WORD (Be Specific): IVePJ to w,ck- � lewe
et- 2- pole�- vvp- W�11 C� 130 ie jeflifiq 2 VO%J tOPC411-r �W;TtjO
C, n 19 L4 (' efopef f -
I WAS STREET OVE RLAYED WITHIN THE LAST FIVES YEARS? YESE] NOE] Year: i
PAVEMENT CUT: E] Yes F-1 No If yes, indicate size of eut: -x
CONCRETE CUT: R Yes F-1 No If yes, indicate size of cut: x
APPLICANT TO READ AND SIGN
*Traffic control and public safety shall be hi accordance with City FegUlatiotis as required by the City
Eiighicer. Every flagger intist be trained as required by (WAC) 296-155-305 and inust have certification
%rerifying completion of the required training in their possession.
*Restoration is to be iiiaccordance with City codes atid Standards. All street -cut tretich work shall be
patched with asphalt or City approved material prior to the ctid of the workday —NO EXCEPTIONS.
Indemnity: The Applicant has signed an application which states he/she hold 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 defense costs and attorney fees by reason
of granting this permit.
I have read the above statements and understand the perrnit requirements acid acknowledge that I must
follow all reqUireinctits in order for the permit to be valid.
SIGNATURE -X-A..&, 1VdAA^,,,
Contractor or Agent
DATE q /' ?- ot / I
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
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LOCATION 9614 L DMONDS WAY �
ENGINEER,Tf'[_VOR VF -'I -A' -)CO - DATE 9/29/17 ORDER 100000442 ctE
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PHONE 425-- 78.3-5096 �
CELLULAR 425..231-_1367 �¢
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LOCATION 9614 L DMONDS WAY �
ENGINEER,Tf'[_VOR VF -'I -A' -)CO - DATE 9/29/17 ORDER 100000442 ctE
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PHONE 425-- 78.3-5096 �
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