City of Edmonds Permit App.pdf0 V- E LA4 -
0 +
(�;99MIR�jl
ROW PERMIT NO.: ENG,
ISSUE DATE:
IA,16—
.)'SC)0 PERMIT APPLICATION
,� A 4,
PROJECT NAME: , 116 04 o CONTACT:
CONTRACTOR:
Mailing Address: 0, %'ox
State License #:
City Business License it:
Phone
Fax fl:
Email#:
F1 Liability Insurance F-1 Bonded
L � 0 C' \/
ADDRESS OR INTERSECTION OF CONSTRUCTION, irl "i "� p "w
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
n Commercial [] Subdivision E:l Cit-y Project iM Traffic Control (Only)
F-1 Multi -Family 0 Single Family
R EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit?
F-1 Other.
'F] Yes F-I No
ANY ASSOCIATED PERMITS? BI,D# ENG#
( " \ � ^11, C, I�, DESCRIPTION OF PROPOSED WORK (Be Specific): -, 0—
\s '�,) uA
') Ao A ll� e N \
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES [j NOE] Year:
PAVEMENT CUT: E] Yes E] No If yes, indicate size of cut: X
CONCRETE CUT: F1 Yes F-1 No If yes, indicate size of cut: x
APPLICANT TO READ AND SIGN
*Traffic control and public safety slrall be ira accordance Nvitlr City regulations as required by the City
Engineer. Every flagger must be trained as required by ( AC) 296-155-305 and must have certification
verifying completion of the required training irr 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 —Nth EXCEPTIONS.
Indemnity. The Applicant has signed an application which stales 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 underslaZbe
the permit requirements and acknowledge that I must
follow all requirements in order; Wi t17 perrr�i valid.
SIGNATURE
,.,, '� ��` w✓
DATE �
Contractor- or° Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
LANE CLOSURE ON A TWO—LANE ROANIF
(TWO FLAGGER OPERATION) I
0 o
Ld 0 ❑
>
U
0
Q
o
0
0
c
G20-2A 'EN#IU ,.
�iCiA&I "�4RM
(OPTIONAL)
`�" i' ► ��Jim
m
R?G1IK: G20-2A
(OPTIONAL)
SPEED SIGN BUFFER
LIMN SPACING (FT)
A, B,C (FT)
i .r
=miofmm
.
ACCOMMODATE PEDESTRIANS THROUGH CONSTRUCTION SITE AS NEEDED
a
m
Z7
0
0
E
W
s
w
0
v
m
c
0
W
t-
ra
a
N
rn
0
0
Co
d
If SNO®HCIh115H COUNTYY TRAFFIC CONTROL PLAN!
PURIC U7[LIT y alsi IC7 Ai0 M1 �
mtq
O
PROJECTAT&T
9227 OLYMPIC VIEW DRIVE E®MIFICATIaN AT &'T O H 2018
LDNDS 0 co
ENGINEER AZIZ HAQ CRATE 6/11/18 ORDER 100031391
PHONE 425-783-5251
CELLULAR
I,. o