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ROW PERMIT NO.: ENG V0,
ISSUE DATE:
livc. 1. j
PERMIT APPLICATION
PROJECT NAME:
2 41 A/ 11,1�A),e-,
CONTACT:
'2 -kr 11:
CiMd 151-4(7
CONTRACTOR: Q
Mun_30Lra. 4� L(�
Phone #:
Mailing Address:
17
4
1-&S� SW A4M4!�'Mlx
Fax I'M/
60 51- -3
State License #:,5r
JAI
Ernail #:
na
- 69 1qU1, c Mpl
City Business License #:
0 17
Liability Insurance
F] Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: /%/")e/ �f Ilt Z' U
ROW WORK. ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
R Commercial 0 Subdivision 0 City Project R Traffic Control (Only)
Fj Multi -Family 0 Single Family
F-1 EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit?
F1 Other
F-1 Yes F] No Job Number
ANY ASSOCIATED PERMITS? � [l3LD#_-Qt/,.R,)3'(�y ENG# &Q C) I �'W
DESCRIPTION OF PROPOSED WORK (Be Specific)
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11FxT,-%,w31FT1WA=,T,1M_— 0 a I I & FA, wass wra w � wo , wv ons, M
PAVEMENT CUT: Yes D No
CONCRETECUT: Yes F] No
If yes, indicate size of cut: x
If yes, indicate size of cut: x
RIGHT-OF-WAY DURATION
AREA TOTAL
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.
INDEMITY: 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 of grantingthis 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.
SIGNA
DATE 11c'--,7
/ f ontrae o or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE