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PER1 '11111" All"J"LICATION
PROJEcr NAME-,
CONTRACTOR -
Mailing Addres
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State License ft:
City Business fAcense I/-
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—'LiZd—ity Insurance Ev" 13ondled
ADDILIESS OR INTERSECTION 0F'C0NSTRTJCT10N-,,,
� ROW WORK ASSOCIATED, WITH THE FOLLOWINGTYPE OF PROJECT -
Commercial
multi -Family
Subdivision
[.-I Single Family
0 E UC (PUD, VERIZON, PSE,
COMCAST, OVWSD)-
Is this permit part of a blanket permit?
City Project:
[:1 Yes [:1 No
Traffic Control (0111y)
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ANY ASSOCIATED PERMITS? ENG# 200700'18
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DESCRIPTION OF PROPOSED WORK (Be Specific) a
[,`-'r(-)ntaqe and utifity construcfiorr fi�)r anew, 27lotsubdivision, hlGhrdes approxwwA,650 ft
of IIZOVV (;wgutter and sidewa�k"' 500 sf of nc)vv rcmd PaVEn'ient (project access)W 50 ft of
"turn-iPuPE.' (2–new CBs)',' 20 ft of watier ima in (and tap); arid 230 ft of sanftm y SEM' rrmki
(and coninectk'm).
WAS s'rREET0VF RLAD WITHIN THE LAST FIVE (5) YE ARS? YES [❑ NO El eaamm
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PAVEMENT CUT: Yes 4 .1
No ]If yes, indicate size of ent. ",� ; ". . ............
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CONCRETE cur: Yes No If yes, indicate size of cut.
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APPLICANTTO READ AND SIGN.
,�cfra:f is control and public safety shall be in accordance with City regulations as required by the City
Engineer, Every flagger ra-ust be trained as required by (WAC) 296-155-305 and fmist have certification
verifying coirapletion 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 appliction which states helshe hold th City of
Edmonds harmless from injuries, damages or clainis of any !tired or description
whatsoever, f r n or unforeseen, that may be rade against the City of Edmonds or
any of its departments or 1 , including df n costs n attorney fees by reason
f granting this permit
I have read the above statements and understand the permit requirements and acknowledge that I must
follow all requirements in
SIGNATURIE
the permit to be valid..
DATE �,,.'
NO W011K HA1-J-, BEGIN P I 1 1`0 1IE1'1llriIT 1 roa. UA1" CI.i.",