392711 Permit App.pdfPROJECT NAME.
CONTRACTOR:,.
Mailing Address: : i s ,µ , k
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State License #:
City Business License #:
ROW PERMIT NO.: ENG
ISSUE DATE:
CONTACT:
Phone #:.,'
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Fax ##:
[:1 Liability Insurance ❑ Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: C �
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT: �
❑ Commercial E] Subdivision ❑ City Pi-oject ❑ Traffic Control (Only)
❑ Multi -Family ❑ Single Family ❑ Othen°
EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? Yes ® No
ASSOCIATED PERMITS? BLIP# EEG#
DESCRIPTION OF PROPOSED WORD (BeSpecific):t a,, µ
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WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES ❑ NO Year:
PAVEMENT CUT: ❑ Yes F1 No If yes, indicate size of curt: X.
CONCRETE CUT: ❑ Yes ❑ No If yes, indicate size of cut: x.
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 111LISt have certification
verifying completion of the required training hi 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 ire/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 statem 4'and understand the permit rCqL1ire1nC11tS and acknowledge that I ninst
follow all requirements in r r for the Permit to be valid.
I / / - 1
SIGNATURE' DATE 11 "
Contaadifb - Agent
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NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
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SNOHO)AISH COUNTY
ERIOM
TRAFFIC
CONTROL PLAN
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FMIC UNLITY DISTRICT NO I
PROJECT REPLACE (3) DEPREICATED POLES
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LOCATION 1012 VIEWLAND WAY
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ENGINEER ANDRE A,-...NEL SON
DATE
4/30/18 ORDER 392711-03
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PHONE 425-783-4394
CELLULAR 425-512-3526
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