100015518 Permit App.pdfROW PERMIT NO.: ENG
ISSUE, DATE:
Zkj�j' 9 0
PROJECT NAME: 3rd ave feeder Cable Replace
CONTRACTOR: S110110,11ish PUD
Mailing Address: PO box 1107
State License #:
City Business License 4:
CONTACT: Trevor Velasco
Phone #: 425-783-5096
Fax fi:
Email #: TLVelascogsnopud.com
F1 Liability Insurance F-1 Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 11093rd ave s,Edmonds
ROW WORK ASSOCIATED WITH THE FOLLOWING TYP i OF PROJECT:
F-1 Commer-cial El Subdivision El City Project Traffic Control (Only)
E] Multi -Family 0 Single Family [I Othet-
R Euc (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? F-1 Yes gNo
ANY ASSOCIATED PERMITS9 BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific): blocking I large of traffic
to pull new powereables through existing underground concluit, and reframe existing, poles
I WAS STREET OVE RLAYED WITHIN THE, LAST FIVES YEARS? YES 0 NO Year:
PAVEMENT CUT: F -I Yes Mr No If yes, indicate size of cut: X.
CONCRETE CUT: E] Yes S( No If yes, indicate size of cut: X.
APPLICANT TO READ AND SIGN
*Traffic control and public safety shall be in accordance with City regUlations as required by die City
Eiigincer. Every flagger imist be trained as required by (WAC) 296-155-305 and 111LISt leave certification
verifying completion of the required training in their possession,
*Restoration is to be in accordance with. City codes and Standards. All street -cut trerell work shall be
patched with asphalt or City approved inaterial prior to the end of the workday — Na 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 statements and understand the perinit requirements and acknowledge that I 111LISt
follow all requirenictits in order for the permit to be valid.
SIGNATURE jt -fl— fV DATE.
Contractor or Agent
NO WORIC SHALL BEGIN PRIOR TO PERMIT ISSUANCE
LANE C L OS U R E ON A TWO -[.ANE LOW-VOLUME F�OAD
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