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ROW PERMIT NO.: ENGA 'I
ISSUE DATE:
RIGHT-OF-WAY CONSTRUCTION
PERMIT APPLICATION
PROJECT NAME: CONTACT: W _._ l
CONT RACTORt-n . m Phone #: '�, - _'91z"k
Mailing Addres1 Fax #:
w
Cit Business License #.'fMl
Emaliabilw Insurance L onded
ADDRESS OR INTERSECTION OF CONSTRUCTION:
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
Commercial
❑ Multi -Family
Subdivision
❑ Single Family
❑ EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit?
City Project
❑ Other
❑ Yes ❑ No
Traffic Control (Only)
ANY ASSOCIATED PERMITS? BLD# CoOf 'i� ENG#_wwwwwwwwwwwwwwwwwwwwwwwwaa�
DESCRIPTION OF PROPOSED WORK (Be Specific) :
'AgE V L d�, w
............ .........._........__...__..................................................... ........
WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES NO X Year:
PAVEMENT CUT:
CONCRETE CUT:
❑ Yes [R No
❑ Yes ® No
If yes, indicate size of cut:
If yes, indicate size of cut:
x
x
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.
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 U - rstaiid the permit requirements and acknowledge that I must
follow all re uirem�, sin- -d'ar ��r t ° enn it t be valid.
SIGNATURE DATE
Conti -actor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
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RECEIVED
JUN 0 6 2016
L)EVELOPMENT SERVICES ROW PERMIT NO.: ENG
CITY OF EDMONDS ISSUE DATE:
DIGHT -OF -WAY CONSTRUCTION
PERMIT APPLICATION
PROJECT NAME: PC-C);>L-f 5
CONTRACTOR:
Mailing Address:
State License #:C.
City Business License #:
CONTACT: �.r fJ� T * %-�
Phone #: )-a(�, (;,,&I — 7/ 2-3
Fax #:
Email #:. i d s 67tnA16, [ZVI)
Liability Insurance Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: Ili ����l� j ( 60(7)0r31 -q5 ._
W WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
Commercial
❑ Multi -Family
Subdivision
❑ Single Family
❑ EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit?
City Project
Other
❑ Yes ❑ No Job Number
Traffic Control (Only)
ANY ASSOCIATED PERMITS? BLD#Z)�BI0 Oa ENG#_
DESCRIPTION OF PROPOSED WORK (Be Specific) :
,
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" � u ,...� P, -.:-:i .° `� /�.:��c^R C'e�L'�^J .P'.,._'J`.. k°, li XL:v:;^'.ft,:: F��:"d°'.?. ��C �T Jr; ,F'L'���'. ,v:'es Y�c•::'.�.a.YJ.z .,,,:+d"f.s:,NdN'aPPw.YW�'€.I"�wl.C..Ndk"i'li. r"c�kA. J����11G 1,�n,.d rC.vk��°.W d.��r
WAS STREET OVERLAYED WITHIN THE LAST FIVE YEARS. YES ❑ NOYear:
� I
PAVEMENT CUT: ❑ Yes No If yes, indicate size -of cut: —X
—
CONCRETE CUT: ❑ Yes No If yes, indicate size of cut: x
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 Ci . ty codes and Standards. All street -cut frencliwork shall be
patched with asphalt or City approved material prior to the end of the workday —,NO EXCEPTIONS.
LN �EM I T �Y.T The
harmj6ss from
er foreseen or u.
that rna be made a cantoveq;, includinp- defense
Costs and attome 'e reason of rantin this errnit.
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.
SIGNATURE,
DATE
n actor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE