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ROW PERMITNO. : ENC M161, (ILA I
ISSUE, DA.TE-
RIGHT -OF. -WAY CONSTRUCTION
PERMIT APPLICATION ,AV
PROJECT NAME-,!,,,,
CONTRACT vp
Mailing Add
(',0.NTACT.
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Phone #.,a
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Fax 4-
State LicLiability Insurance '
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City Business License 4. R ondeff
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ROW WORK ASSQCIATED WITH THE FOLLOWING TYPE OF PROJECT:
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0 Commercial E71 Subdivision El City Project Traffic Control (Only)
-Fainily
Muld
[:1 Single Family
[:1 EPIC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this perp -tit part of a blankl et permit'?
ANY ASSOCIATED PERMI
DESCRIPTION OF PROPOSED W (Be Specific):
WAS STREETOVERLAVED WITHIN THE LASTFIVE (5) VEARS? 'ES.R No
, ELI
PAVEMENT CUT- El Yes I .. . .... . ....... I [No 1.1'yes, indicate size of cut: X
CONCRETE CUT: El Yes U No 1.1'yes., indicate size of cut: . . ... . ......................... .
APPLICANTTO RE AD AND SIGN
11'raffic control and public safely slialI be in accordance with City FCC�Ulatjoris as reqnired by the CityZ�l
Engineer. Every flagger mast be trained as reqt6red by (WAC) 296-155-305 and niust 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 helshe hold the City of
Edmonds harrnless 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 attomey fees by reason
of granting this permit.
I have read the above statements and Linderstand the Permit requirements and acknowledge that I Inust
follow all reqtti"Ss in order foi- the perrnit to be valid.
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Contr,actoi- 6r Age'
NO WORK SHALL BEGUN IIPRIO1 TO PE .1°t ISSUANCE