257638 - 16404 75th PL W, Edmonds.pdf
ROW PERMIT NO. : ENG___________
ISSUE DATE: ________________
RIGHT-OF-WAY CONSTRUCTION
PERMIT APPLICATION
PROJECT NAME: CONTACT:
DPNDBTU
CSFBOOBTXJGU
CONTRACTOR:Phone #:
536.459.8846
QBDJGJDDBCMFDPOTUSVDUJPO
Mailing Address: Fax #:
536.459.8:77
QPCPY684XPPEJOWJMMFXB:9183
Email #:
State License #:
CSFBOOBAQBDDBC/DPN
QBDJGDD:65QK
City Business License #: Liability Insurance Bonded
Y
Y
OS.133451
ADDRESS OR INTERSECTION OF CONSTRUCTION:
16404 75TH PL W
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
Commercial Subdivision City Project Traffic Control (Only)
Multi-Family Single Family Other
Y
EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? Yes No
Y
BLD#____________ ENG#____________
ANY ASSOCIATED PERMITS?
INSTALL CATV SERVICE LINE.
DESCRIPTION OF PROPOSED WORK (Be Specific) :
BORE A TOTAL OF 126FT IN THE ROW. 96FT SOFT SURFACE, 30FT HARD SURFACE CROSSING
75TH
_________________________________________________________________________
WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES NO Year:
PAVEMENT CUT: Yes NoIf yes, indicate size of cut: _________x_________
X
X
CONCRETE CUT: Yes NoIf yes, indicate size of cut: _________x_________
RIGHT-OF-WAYDURATION
AREATOTAL
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 he/she hold the City of
Edmonds harmless from injuries, damages or claims of anykind 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 must
follow all requirements in order for the permit to be valid.
9-23-2017
SIGNATURE DATE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE