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PROJECT NAME:+^^otl ôF_CONTACT: KcÀ
Row PERMIT No. tF]NG-7)üthþi%'
ISSUE DATE:
RIGHT-OF.\ilAY C ONSTRUC TION
PERMIT APPLICATION
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CONTRACTOR: q,1 .t [l¡r¡,.es lr.r Phone #:4ZS'T\z'GoL{¿/
Mailing Address: les3t t3t." A.e. S. K";lc Êt0+Fax #:4LS-+\L-SolL
State License #\.F,
City Business License #r ñt¿ - OZ q+VZ
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ADDRESS OR INTERSECTION OF CONSTRUCTION:
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
Commercial Subdivision City Project
Other
Traffic Control (Only)
I Mutti-Famity t] Single Family
n EUc (PUD, vERrzoN, PSE,
coMCASTo OVWSD):
Is this permit part of a blanket permit?lYes INo
ANY ASSOCIATED PERMITS?BLD#ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific) :
WAS STREET OVBRLAYED WITHIN THE LAST FIVE (5) YEARS? YES No f-l Year:
PAVEMENT CUT:
CONCRETE CUT:
! ves
f, ves
INo
INo
If yes, indicate size of cut: x
Ifyes, indicate size ofcut: x
RIGHT-OF'-WAY
CLOSIJRE
AREA TOTAL
DURATION
(NUMBER OF',MONTHS)
Sidewalk 48 Hrs +LF'x LX'SF
Llley 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 Cþ
Engineer. Every flagger must be trained as required by (WAC) 296-155-305 and must have certification
verifiring 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.
lndemnity: The Applicant has signed an application which sfaúes 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 depaftments or employees, including defense cosfs 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 the to be valid
SIGNATTJRE DATE +.3( ttr
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE