ENG20170020-APPLICATION.pdfROW PERMIT O. ENG
ISSUE DATE:
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PROJECT NAME: CONTACT:
V, k,
CONTRACTOR:,,
Mailing Address: Ip
State License #:
City Business License #:
ADDRESS OR INTERSECTION OF CONSTRUCTION:
Phone #:
Fax 4:
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Email #:
Liability Insurance ❑ Bonded
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
0 Commercial El Subdivision ❑ City Project -E
I Traffic Control (Only)
[] Multi -Family El Single Family
0 EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this pert -nit part of a blanket permit?
F1 Other
D Yes [9 No
I
ANY ASSOCIATED PERAUTS9 BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific): )1, H64xm
A J(l Ik4l"("
, � ("� 41, ti1,11 Ghfi' k'
41"i U 4 7-
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YESE] NOE] Year:
PAVEMENT CUT: 7 Yes 7 No If yes, indicate size of cut: x
CONCRETE CUT: El Yes M No If yes, indicate size of cut: _X
RIGHT-OF-WAY DURATION
AREA TOTAL
CLOSURE (NUMBER OF MONTHS)
L
SF
SF
TOTAj i
Sidewalk 48 Hrs + LF X LF SF
Alley 72 Hrs + LF X LF S
'F
Parking 72 Hrs + LF X LF SF
ISONSWISOM
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 cornpletion 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.
Y
of granting this permit.
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 i
Contractor or Agent
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