eng20130533-HWA-ROW app.pdfRO'W PEBMIT NO.: ENf(
ISSUE DATE.
RIGHT-OF-WAY CONSTRUCTION
PERMIT APPLICA"HON
PIR.03 ECT NAME: ACT:
CONTRACTOR: Phone#: Z
Mailing Address- 2 31.7 3 4_ j7 1Fax fl:
7 M", ) I
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State License #: �, W) 4 0-1 3,9V Email
City Business License#:A D Liability Insurance ❑ BlgdFO
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17777
ADDRESS OR IWERSECTION OF CONSTRUCTION- �yr SL' C51,CX-14
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
Commercial Subdivision C'ity Pro ect Traffic Control (Only)
[:1 EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD)-
Is this pen -nit part of a. blanket pcn-nit'? D Yes 54 No
ANY ASSOCIATED PERMITS? BLD4 ENG4 I
I)ESCRIPTION OF PROPOSED WORK (Be Specifiv): 4 AI&
-T"b W5j"At-L- 6 51-X)P06 j/J9))C-/VTbeZ. 010-AddTVA- llil--- Fc -,V2
WAS STREETOVERLA"ED WITHIN THE LAST FIFE (5) YEARS? YES D NOE] Year:.
PAVEJVIENTCU'T9 Yes [-1 No
CONCRETE CUT. 0 Yes L-1 No
If yes, indicate size of cut:
If yes, indicate size of cut:
*'Fraffic 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.
signedIndemnity: The Applicant has an, application which states helshe hold the City of
damagesEdmonds harmless from injuries, description
whatsoever,foreseen
any of its r mrtments or employees, including ade
against the City of Edmonds or
permit. costs and attorney fees by reasonof'grantihg this
I have read the above statements and understand the permit requirements and acknowledge that I must
follow all requirements in order for the pen -nit to be valid.
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1N AT'IJIII _.. .� aDATE '/(%'r
Contractor or .gent
O WORK SBALIJ IIEGIN VIt 01 `I'C PEIfMIT ISSUANCE