CHC-ROW Permit Application.pdfBaa
ROWPERMIT NO, - U,'NG_)'l)'-
-44 11
ISSIJE DAIT:
RIGITT-0.11".-WAY C0N's'rRtjc,u0N R E S
PE.11MI"I'APPI-41CATION RJHN, 2,�',`,
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MailialgAddr",s: 3,100— "1' �c"'
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State License 4; JRABBC1022,17
City Business (Aceme M NR016258
CONTAC."I', Mlichael Sloaawy, ofr
206-380-8312
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ADDRESS OR INTERSECTION OFCONSTRUCTXON� (, A 7
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. . .... .....
[ROW WORK ASSOCIATED WITH YHE F01.1110WINGTYPE 0JF,'P.R0JEC'T-
Commercial SlAbdivision Cityllroject Traffic Conct-ol (Oinly)
El Multi -Family ElSingleFamily
V('11 t I VERTZOTN,l(lf
Is this perini(part o I a blankot permit?
0 Other
L] Yes [I No
A'N"'Y ASSOCIATED Pf--',,R.Ml.'FS? BLD4 j_"j I t-71*111
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DESCRIPTION OF PROPOSED WORK (Be Specifile)
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1^5�,Axt'IS
1) 1 ea pt 614ov,
0"'IWAJ 4
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Wty 99'
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WAS WITIMN "I'llE LAS"I" VCAIV,,"? VilS NO Year.
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p�l �li'vo 5'�" &
PAVENH."Nll' Yes ffycs, halicak, sive of`vid� 0!, x 1
N o . . ..... ... . . ....
CUT. Ves No ll'yes, in(JUcatesize ofcut: 111 14:
GMT -0Y °M
Si d ew a
114 48 TIrs 4- 1 T6" 1 x 335"
My 72 M 4- 14' N
ParMing 72 EUs + 11' x
jfyk��, I DMIATION
(NUMBE'I,�, 01��, MONTHS')
*512 SI TBC[,, intermitteint
14'
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APPLICANT TO READANDSIG'IN
MaMe contad and pubHe salelysh"'Id be I ncumAmwe, vvilj,l City re�tjj,,Gons as reqUired, by the (�jty
Engineer. Livery Vqgger nnmt be sked as required 1.�y (WAQ 29&15&305 and rnustl,ravc certifleation
VQII'ifyin,g completkni of the requhvd tritining in their possession.
Smsuwation is to be iti accordance with City cocles and Standards. All street -cut treDej, work NMI be
Patched with,11SPIERI(orCity approved materia.1prior to We end of the wor'kday NOE'ACEPTIOP4S,
Indeninity: The Apphcant has shynmi an IN)"liCh MF)k?sA;fwe hole"I tho'.,� CR
",
Edrnonds hartnk,,�ss finn,�j ir�jklries, cfamages cj itns of any khmi or " Mcdpejon,
omhatsoeveq homsewl or ankmaseen, timit rnay be niarle against 94,we of
y of itsdepailments op"EMIPIOYees, incioding defense cosj,.S and attorney Ses by mason
of granting this permit.
I have read the above stAenjwAs and undustand the permit reg irements and acknowledge that T ITILISt
Follow all tepirenitints in order for the permit to be valid,
ST(MALT UIRUE 06,0/2013
DATE
NO WORK SHAIJ, BEGIN PRIOR TO