100015176 Permit App.pdfof EVA10 4/
ROW PERMIT NO.: ENG,
ISSUE DATE:
19mol ON 01, 1 " N WINMEN w V I
. 1.v 0
-
PROJECTNAME: Wey4-&Me
� pottee-5 CONTACT: Trevor V'Olm5co
CONTRACTOR: 5%® PQO
Mailing Address:
State License 4:
City Business License 4;
ADDRESS OR INTERSECTION OF CONSTRUCTION:
Phone 4:
Fax #:
Email #: -r- 1, Vel�4 60 6) 5no PW. Com
Liability Insurance F1 Bonded
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F1 Commercial El Subdivision 0 City Project W] Ti-affic Control (Only)
El Multi -Family F] Single Family F-1 Otbei-
[I EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD)-
Is this permit part of a blanket permit? El Yes El No
I
ANY ASSOCIATED PERMITS? BLD# ENG#
P I
DESCRIPTION OF PROPOSED WORK (Be Specific): Leq-weaA
D NJ 14t --f5 6e -r weevi A0 Aevv w'i't)
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES F] NO M Year:
PAVEMENT CUT: F-1 Yes M No If yes, indicate size of cut:
CONCRETE CUT: RI Yes No Ifyes, indicate size of cut:
x
x
RIGHT-OF-WAY
AREA A TOTAL
CLOSURE
. .. . . ........
Sidewalk 48 Hrs + LFX 7 LT Sr SF
Alley 72 Hrs + LF X LF SF
Parking LF X LF SF
DURATION
(NUMBER OF MONTHS)
APPLICANT TO READ AND SIGN
*Traffic control and public safety shall be in accordance witli City regulationsas 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 witil City codes and Standards. All street -cut trench work shall be
patelied witli asphalt or City al)proved material prior to the end of the workday — NO EXCEPTIONS.
indemnity. The Applicant has signed an application which states helshe 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 staternents and understand the permit reqUirernents and acknowledge that I must
follow all requ ire nie tits in order for the permit to be valid.
SIGNATURE 'v&t1'— DATE
Contractor, or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
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