20160421113323.pdfwd
ROW PERMIT NO.: ENG
ISSUE DATE:
RIGHT-OF-WAY CONSTRUCTION
PERMIT APPLICATION
PROJECT NAME: CONTACT:
CONTRACTOR: � � � . Phone #:
Mail
ing Address:y �"' w, 1. Fag #. SIA
State License #. Email #: � Si � /� Li Lk --e Co"
"it Business L�ccnse #: LiabilityInsuranceBonded
ADDRESS OR INTERSECTION OF CONSTRUCTION:
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
Commercial
❑ Multi -Family
Subdivision
❑ Single Family
❑ EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit?
City Project
❑ Other
❑ Yes �(No
ANY ASSOCIATED PERNIITS? BLD# ENG#
Traffic Control (Only)
DESCRIPTION OF PROPOSED WORK (Be Specific):L).,'L�J6"A���+ � � 1" � �
M
,._
( JJor 1L 1 A� t/0 C_y
WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES NO Year:
PAVEMENT CUT: ❑ Yes XNo If yes, indicate size of cut:
CONCRETE CUT:Yes ❑ No If yes, indicate size of cut: g oe
RIGHT-OF-WAY DURATION
CLOSURE AREA TOTAL (NUMBER OF MONTHS)
U
Sidewalk 48 Hrs + LF X LF
_._ . ..,.,.., ... AJC
Alley 72 Hrs + LF X LF SF
Parking 72 Hrs + W ...._. LF mm. mX XLF 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 nwst.
el
.1 ��
follow all requirements in o r�Ilee. to be valid,
SIGNATURE DATE
entractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE