20140814101314348.pdf_, OV- EDA,1,r-),
ROW PERMIT NO.: ENG'(t
ISSUE DATE:
PROJECT NAME:
CONTRACTOR:
"Phone
7 V
Mailing Address:"j,
Fax 9
State LicenseEmail
,4,44
City Business License Liability Insurance F]"Honded
ADDRESS OR INTERSECTION OF
W17MITI-Im.
Subdivision
[:] Single Family
F EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit pail of a blanket permit?
City Project
IN
El Yes 0 No Job Number
ANY ASSOCIATED PERMITS? BLD#
ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific):
Traffic Control (Only)
WAS STREET OVERLAYED WITHIN THE LAST FIVES YEARS? YES [:1 NO [:1 Year
L
PAVEME NT CUT:
191300610111111104111
[—] Yes El No
D Yes El No
If yes, indicate size of cut:
If yes, indicate size of cut:
0
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.
fNDEMITY: 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.
7
SIGNATURF DATE
Contractor or Agent