20150929113411.pdfROW PERMIT NO.: ENG_ ?�f� 9��
ISSUE DATE:
RIGHT-OF-WAY CONSTRUCTION
PERMIT APPLICATION
PROJECT NAME � � CONTACT:
Phone
CONTRACTOR l�C
Mailing Address:pj) jjj 00
Fax #:,,,,,,
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State License #- )' 14 I'--
City Business License#:
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ADDRESS OR INTERSECTION OF CONSTRUCTION: goo r -G ��yy�lYlG�-� Q;o
ROW
lORK ASSOCIATECoercial Subdivision City Project Traffic Control (Only)
❑ Multi -Family ❑ Single Family
K EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit?
E] Other
❑ Yes ❑ No Job Number
ANY ASSOCIATED PERMITS?"�!.'.
DESCRIPTION OF PROPOSED WORK (Be Specific) :
._.
WAS STREET OVERLAYED WITHIN THE LAST FIVE YEARS9 : YES ❑ N "Fear: 17
PAVEMENT CUT: ❑ Yes a o If yes, indicate size of cut: .-x
CONCRETE CUT: ❑ Yes 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 the City
Engineer. Every nagger must be trained as required by (WAC) 296-155-305 and must have certification
verifying completioil 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,
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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