eng20130323-PUD ROW application.pdfROW PERMITN'0. ; LING
-
ISSUE DATE.
RIGHT-OF-WAY CONs'rRUCTION
ilvc. jjac)0 I v orK Or er
PERMIT APPLICATION
385857
PROJECT NAME: CONTAC' i�
�J
CM Cl TRACTOR -
11C
Mailing Addrew qFax If:
-I u ........... ...... . . . . .
State License fta P nae aai
4, �,1'
City Business License Liability Insurance B011(i (I
. . . . ....... .. -
ADDRESS OR IN'rERSECTION OF CONSTRUcriON.
I .... . . .... . ....
ROW WORK ASSOCIATED WITH THE F0LL0WlNG'F)PE_,QF PROJECT:
F] Conimei-clal El Subdivision ❑ City Pi -eject Tniffic Control (0111y)
N,
Multi-Mgmily El SingleFamily FA Other
O(EUC (PUD, VERIZON, PSE,
MCAsT, OVWSD):
Is this permit part of a blanket permit? El Yes El No
SSOCIATED PERMU:S�? BLD4 ENG#
DESC OF PROPOSED WORK (Be Specific): c. 4A., 1-(- ) r
-A
yd
'PE)
M po" 7
L LZ
WAS's'rREET OVERLAVE D
WITHIN THE LAST FIV (5) YEARS? YES El NO 0 Year: ti
PAVEMENT CUT:
F1 Yes
0 No
If yes, indicate size of cut:
CONCRETE CUT-
[:1 Yes
E:l No
If yes, indicate size of cut. x
APPLICANT 'O RE D -
"Traffic control and public safety shall be in accordance with City regulations as required by the City
Engineer, Every flagger roust be trained as required by (WAC) 2967155-305 and rmist have certification
verifying completion of the required training in their possession.
*Restor'atioii is to be in accordance witli City codes and Standards. All street -cert 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 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 understand the pertuit requireMents and acknowledge that I roust
follow all requirements i rder for the pert 't- o be valid.
SIGNATURE 44-11124
� DATES-30'
Contractor ot• agent
NO WORK SHALL 13EG N PRIOR TO PERMT T ISSUANCE
0' tributiart N'h�t Da�purtment Respdn®ible For Work -Return To 06*otor When Completed Blua-61S, 03, After Work Completion
Canary-0apartment Responsible For Work -File Copy Pink -Originator
SPRINT — SE63XC212 — PINE RIDGE
CONSTRUCTION OPERATIONS
AND ENGINEERING REQUEST
1818 Rev. 11/98
TO
FROM
DATE
CONSTRUCTION
ANDERS DAHL 425-512-7706 05/29/2013
ADDRESS/LOCATION/POLE NUMBER
8730 MAIN ST, EDMONDS /
19(27-°4).3 / L -B 2/6
MAP NO.
WORK ORDER NO. TASK NO.
454-6J
385857
03
PLEASE ASSIST SPRINT WITH INSTALLING 2 NEW ANTENNAS ON NEW DUAL ANTENNA MOUNTS
2 RRH P4'S, 2 FIBER RUNS
IN EXISTING CONDUIT.
817 815
` FU40
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For de -energizing customer service for Customer work
CUSTOMER CREW HOURS
When completed, call
the PUD at 425-783-1000
Signature
Customer 5i g
Date
or (1-877-783-1000) ask
for Energy Control Dispatch
APPROVE �Y
COMPLETED BY
DATE
0' tributiart N'h�t Da�purtment Respdn®ible For Work -Return To 06*otor When Completed Blua-61S, 03, After Work Completion
Canary-0apartment Responsible For Work -File Copy Pink -Originator