20160615075737.pdfOf EDA,,10
ROW PERMIT NO.: ENI 9d 1
ISSUE DATE:
RIGHT-OF-WAY CONSTRUCTION
'• i SCJ° PERMIT APPLICA"T"ION
PROJECT NAME: 4 LCA a,4 -P- CONTACT: P& �c
CONTRACTOR � Phone #: '° � %U l�
Mailing Address: Fax #:
• Email #•
City llusi ss License #: v2 h �U �- Liability Insurance Bonded'�
ADDRESS 0INTERSECTION 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 Z No
Traffic Control (Only)
ANY ASSOCIATED PERMITS? BLD# � aC3 ENG#m IT_
DESCRIPTION OF PROPOSED WORK (Be Specific)
O �Uu ."
WAS STREET OVERLAYED WITHI � �_...._ ...... ❑ .....� IT
N THE LAST FIVE (51 YEARS? YES NYear:
PAVEMENT CUT: ❑ Yes ❑ No If yes, indicate size of cut: x
CONCRETE CUT: ❑ Yes ❑ No If yes, indicate size of cut: x
RIGHT-OF-WAY DURATION
AREA TOTAL
CLOSURE (NUMBER OF MONTHS)
Sidewalk 48 Hrs + 8 LF X '57 LF SF
.............. _ m .. ....
Alley 72 Hrs + LF X LF SF
Parking 72 Hrs + . LF X....._. ._ I, ...._
F 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 hel he 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 abov st, enients nd understand the permit requirements and acknowledge that I must
follow all requires o' der or the permit to be valid.
SIGNATURE
7.1 DATE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE