bld20160101-ROW application.pdfROW PERMIT NO.: ENG-Z41�-alAgI
ISSUE DATE:
RIGHT-OF-WAY CONS`I'RUCTION
L RMIT APPLICATION
PROJECT NAME:
v.��
SCrEN�C ��SzorNCE
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CONTRACTOR:
AQyAL3NF P60L a SDA
Mailing Address:
5631 1600N st SW , SIS At
lel MAi Wang _ IMA 9 Fr03 6
_ ...
State License #:
ACNALpSg633'r
Cit Business
City ...... m _ .License
CONTACT:SG►�ENK-
.................................... .� .
Phone
(WO 351- 4480
..... ...... ._ .... . _�. �.. _........�
Fax #: (?06) 31q • GOOq
Email #: MAz L - G0AA
Liability Insurance Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: q 10 101 H WE N , EDM0N0S , WA 01(0?0
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
Commercial [� Subdivision [ City Project Traffic mmmmm�
ontrol (Only)
❑ Multi -Family N Single Family
❑ EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit?
❑ Other
❑ Yes 19 No
ANY....... ASSOCIATED PERMITS? FLD# ao�s0oe� ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific) : EX16NO CVR6 CWT 04N
161A AciE ►JoQ-ltrk In ArrrwArA-11; aW -r o�7.1y�1►tA'f. P17�2 r_n�Jr.t�E f� FOR.
DSZTQE-tgAY SAJ 7HE,l ( OF wA`r.
.......... __ �..
WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES NO M Year:
PAVEMENT CUT: ❑ Yes [N No If yes, indicate size of cut: e. r......�......_........_.
CONCRETE CUT: 0 Yes ❑ No If yes, indicate size of cut:. _,,,,— a"I �.LLw��,. r
RIGHT-OF-WAY DURATION
CLOSURE AREA TOTAL (NUMBER OF MONTHS)
Sidewalk 48 Hrs + LF X LF SF
Alley 72..H.
rs + LF X LF SF
Parking 72 H ........
rs + 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 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 statements and understand the permit requirements and acknowledge that I must
follow all requires 1p-nts in order for the permit to be valid.
SIGNATURE --" DATE 3
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE