19311 88 AVE W-APPLICATION.pdfof EVtyo
100011942
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PROJECT NAME:
ROW PERMIT NO.: ENG
ISSUE DATE:
RIGHT—OF—WAY CONSTRUCTION
PERMIT APPLICATION
CONTRACTOR: �V�A
MailingAddress: 16,6y tloz�
State License
City Business License 9:
CONTACT: kca� �k&Q
Phone #: Lj�,5- - -jc� b - 5�-d,5- k
Fax #:
Email#:
F] Liability Insurance F] Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION:
EAM.&A-, VN &I eb- 0 aA
ROW WORK ASSOCIATED WITH THE FOLLOWING TYrE OF PROJECT:
F-1 Commercial F-1 Subdivision 0 City Project rq-,Traffie Control (Only)
F� Multi -Family El Single Family F1 Other
X EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this pertnit part of a blanket permit? 0 Yes El No
ANY ASSOCIATED PERMITS9 BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific): rk-
iA4e_' mf-40%'�A C,\\ �ke� 0A, �rlvvk c2n
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YESE] NOE] Year:
PAVEMENT CUT: El Yes No If yes, indicate size of cut: x
CONCRETE CUT: El Yes No If yes, indicate size of cut: x
RIGHT-OF-WAY
AREA
CLOSURE
TOTAL
DURATION
(NUMBER OF MONTHS)
I
Sidewalk 48 Hrs + LF
X
LF1
SF
Alley 72 Hrs + LF
X
LF
SIT
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 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 permit requirements and acknowledge that I must
follow all requirements in oSAer forfi�g,.
,p4mit to be valid.
SIGNATURE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Im
[P[O ' F-D-1 CONSTRUCTION OPERATIONS AND ENGINEERING REQUEST
818 R v. 11/98
TO FROM JDATE
KEITH ELI-ISON �A717 HAO -4,25-763-5251 11/9/2017
ADDRESS/LOCATION/POLE NUMBER
'10311 88TFI AVf,' W, [U)MONDS 98026
MAP NO. WORK ORDER NO. TASK NO.
4 C34 -,I �1, �100011942 30
ASSIST CLCARWIRE IN THE REMOVAIL OF ALL CLLARVVIRE OWNED IE-OUIPMENT
EQUIPMENT INCLUDE'�� ANI'ENIIA�--;,-I'IV�A'S,S�l-ANDOFF- F-',-RACI<E'I-SCONDUI-f,FILIER,E'FC
COOF-4DINATE kNITH KRIS CONAXIS 206-310-6732 - [<RISTOPHER,CONA)(IS�QSI'-�RIN'f.COM
P0[.E [1EIGHT. 79" AGL. 68TH AVE ISNO4521
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NORTH
I C L LA R W 111 E TO "I'A K [-� POSSESION AND DISPOSE OF' ALL REMOVEL) EOUIPMENT
For de -energizing customer service for Customer *ork CUSTOMER I CREW HOURS
Customer Signature
APPROVED BY
When completed, call
the PUD at 425-783-1000
or (1-877-783-1000) ask
Date for Energy Control Dispatch
COMPLETED BY
DATE
Distribution: While - Deportment Responsible For Work -Return To Originator When Completed Blue-GIS. 03, After Work Completion
Conory-Deportment Responsible For Work -File Copy Pink-Or�inotor
LANE CLOSURE ON A TWO-LANE ROAD
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SNOHOMISH CO
EP 11 T-M 'T R A F F I C (_�,,'O N TR 0 L P [A N
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PROJECT CLEARWIRE MOTH AVE SN0452 DECOM E
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LOCATION 19311 BOTH AVE W, EDMONDS 9G026 0 r,
ENGINEER A/IZ HAO DATE 1/9/2017 100011942 c
ORDER
PHONE 425-M55251 " I oll
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