1802BHDM.17_ROWI_EDM_0343__ROW Application.pdfROW PERMIT NO. : ENG___________
ISSUE DATE: ________________
RIGHT-OF-WAY CONSTRUCTION
PERMIT APPLICATION
PROJECT NAME: CONTACT:
CONTRACTOR:Phone #:
Mailing Address: Fax #:
State License #: Email #:
City Business License #: Liability Insurance Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION:
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
Commercial Subdivision City Project Traffic Control (Only)
Multi-Family Single Family Other
EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? Yes No
ANY ASSOCIATED PERMITS? BLD#____________ ENG#____________
DESCRIPTION OF PROPOSED WORK (Be Specific) :
_________________________________________________________________________
WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES NO Year:
PAVEMENT CUT: Yes No If yes, indicate size of cut: _________x_________
CONCRETE CUT: Yes No If yes, indicate size of cut: _________x_________
ARNALDO BLANCO
(787) 349-2960
ABLANCO@FG-INC.NET
(770)368-1944
MASTEC NORTH AMERICA, INC.
151 STEWART ST SW, BLDG A,
PACIFIC, WA, 98047
MASTENA991KJ
19556 FREMONT AVE (SALTWATER PARK
16 PHASE IV)
FRANCHISED UTILITY-MCI METRO ACCESS TRANSMISSION SERVICES, LLC
RIGHT-OF-WAY AT 8201 LAKE BALLINGER WAY
USE OF THE RIGHT-OF-WAY TO
ATTACH TO 6 POLES, INSTALL 692 LF OF AERIAL STRAND, (2) ANCHORS AND TO PULL
FIBER OPTIC CABLE. INSTALLATION IS IN THE RIGHT-OF-WAY OF LAKE BALLINGER
WAY.
RIGHT-OF-WAY
CLOSURE AREA TOTAL DURATION
(NUMBER OF MONTHS)
Sidewalk 48 Hrs + LF X LF SF
Alley 72 Hrs + LF X LF SF
Parking 72 Hrs + LF X LF SF
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 order for the permit to be valid.
SIGNATURE DATE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
03/29/2019