100008823 Permit App rev 1.pdfEM10
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PROJECT NAME1"Jqirork, 4" CONTACT:
f
:
CONTRACTOR: Phone (706
Mailing Address: Fax #:
State License 4:
City Business License #:
Email #:
❑Liability Insurance F1 'Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 9227 Olympic View Drive
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
0 Commercial n Subdivision n City Project [:1 Traffic Control (Only)
❑ Multi -Family El Single Family
,rl"`E,UC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit pail of a blanket perinit?
D Yes El No
� ANY ASSOCIATED PERMITS? BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific):
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES E] NO E] Year:
PAVEMENT CUT: F-1 Yes F-1 No If yes, indicate size of cut:
CONCRETE CUT: F Yes ❑ No If yes, indicate size of cut:
X
P
RIGHT-OF-WAY DURATION
AREA EE
TOTAL
CLOSURE (NUMBER OF MONTHS)
Sidewalk 48 Hrs + LF X LFTSF
Alley 72 Hrs + LF X LF SF
Parking 72 Hrs + LF X LF SF
LLA 5E
APPLICANT TO READ AND SIGN
*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 and Standards. All street -cut trench work, shall be
patched with asphalt or City approved material prior to the end 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 permit requirements and acknowledge that I must
follow all requirements in er for the permit to be valid.
SIGNATURE DATE
Contraethf'r Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
MIMMEMSEEM111i
EPEOM
CONSTRUCTION OPERATIONS AND ENGINEERING REOUEST
1818 Rev. 11/98
TO _7FROM DATE
CONSTRUCTION JANDERS DAHL 425-512-7706 7/24/2017
ADDRESS/LOCATION/POLE NUMBER
9227 OLYMPIC VIEW DRIVE EDMONDS 13(27-3)1/ 263462
MAP NO. WORK ORDER NO. TASK NO.
454-2H 100008823 0030
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When completed, coil
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Customer Signature Dote for Energy -Control Dispotch
APPROVED BY, 1COMPLETED BY DATE
Oistribution: Wile -Deportment Responsible for Work -Return ToOri*tor When Completed Blul 03, After Work Completion
Conory-Deportment Responsbie For Work -File Copy Pink-Originotor
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PROJECT AT&T EDMONDS BEACH MODIFICATION E
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LOCATION 9227 OLYMPIC VIEW DRIVE EDMONDS, WA 0
ENGINEER ANDERS DAHL DATE 7/24/2017 ORDER 100008823
PHONE 425-512-7706 YN
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