161205 MAD (Right of Way Application).pdfUlf IVAM
ISSUE DATE:
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��T NAME: , CONTACT
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CONTRACTOR:
Mailing Address: fe> I f 8
State License #-
City Business License #:
Phone#:
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Email #:
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Subdivision
F-1 EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this Dermit Dart of a blanket DerifLit?
351w=
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ANY ASSOCIATED PERMITS? BLD# ENG#
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PAVEMENT CUT:
F Yes F1 No
[:1 Yes F No
If yes, indicate size of cut: x
If yes, indicate
RIGHT-OF-WAY
CLOSURE
DURATION
(NUMBER OF MONTHS)
Sidewalk 48 Hrs +
Parking 72 Hrs +
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 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
of granting this permit.
I have read the above statements and understand the permit requirements and acknowledge that I must
follow all requirem in order for the permit to be valid.
SIGNATURE rNP-") b h DATE .7
Contractor or Agent