ENG20170173-APPLICATION.pdf1 of EDAtr-j,
PROJECT NAME:
CONTRACTOR:
Mailing Address:
State License #: ,
ROW PERMIT NO.: ENG - 173
ISSUE DATE:
RIGHT -OF -'SAY CONSTRUCTION
PERMIT APPLICATION
CONTACT: 64,
Phone #
Fax #:
Email #:
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City Business Licens Liability Insurance Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION:
ROW �WORK ASSOCIATED WITH T ------E!-. .......
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HE FOLLOWING' "YPE PROJECT:
Commercial Subdivision City Project Traffic Control (Only)
Multi -Family ❑ Single Family ❑ Other
❑ EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? ❑ Yes ❑ No
ANY ASSOCIATED PERMITS? BLD# ENG#
.
.....................
. . .....
WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES NO Year:
PAVEMENT CUT: ❑ Yes No
CONCRETE CUT: ❑ Yes No
If yes, indicate size of cut: x
If yes, indicate size of cut: x
I
RIGHT-OF-WAY I AREA I TOTAL L DURATION
CLOSURE
Sidewalk 48 Hrs + II LF II X I LF 1 SF
Alley 72 Hrs + 11 LFX LF
Parking 72 Hrs + LF X LF
'l tri
oW
(NUMBER OF MONTHS)
0 ` ma
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 understand the permit requirements andacknowledge that 1 must
follow all requirements in or r 1" h pe to be valid. r
4
SIGNATURE DATE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
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