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ROW PERMIT NO.: ENGJI��
ISSUE DATE:
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RIGHT-O&WAY CONSTRUCTION
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PERMIT APPLICATION k/
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PROJECT NAME: cc L
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CONTACT: CA_
CONTRACTOR: �C_
Phone#: /7�5— 7 7-
Mailing Address:
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Fax #-
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Email #: 4-4 �)01,yn4_41
City Business License #: A/k Oo_loll-/5�2_
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Liability Insurance BonAed
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ADDRESS OR INTERSECTION O�CONSTRUCTION:
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I ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT: I
Commercial
N Multi -Family
Subdivision
[9 Single Family
F EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit?
City Project
Other
F1 Yes 0 No
I ANY ASSOCIATED PERMITS? I BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific):
Traffic Control (Only)
Grind transition areas as shown on the drawing. Excavate 4" Of material from 20'x 20' area shown on
thedrawing. Load and haul away all unusable material. Place 2" of crushed rockand2" Of Y2- HMA
inthisarea. Clean, tack, pre -level half of existing road and overlay as shown with 2" of 1/YHMA. Place
new berms where indicated on the drawing.
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EET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES 0 NO 0 Year:
PAVEMENT CUT:
�4 Yes
F] No
If Yes, indicate size of cut: X
CONCRETECUT:
El Yes
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L# No
If yes, indicate size of cut: X
RIGHT-OF-WAY
DURATION
AREA
TOTAL
CLOSURE
(NUMBER OF MONTHS)
Sidewalk 48 Hrs + LF
X
LF
SF
Alley 72 Hrs + LF
X
LF
SF
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 bov atements and understand the permit requirements and acknowledge that I must
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follow all requirement in order for the peppit to be valid.
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SIGNATURE DATE (0
Contractor or Agent
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NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
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