ENG20170223-ROW.pdfuITY OF EDMONDS
121 5TH AVENUENORTH - EDMONDS, WA 98020
PHONE: (425) 771-0220 - FAX: (425) 771-0221
*PERMIT MUST BE POSTED ON JOBSITE*
Job Address: 396 SUNSET AVE N, EDMONDS Location
MIKE & CRYSTAL LANNING PACIFIC EMERALD HOMES INC;
PO BOX 9 PO BOX 822
EDMONDS, WA 98020 EDMONDS, WA 98026
LICENSE #: PACIFEH090KZ EXP: 08/23/2018
Driveway and Utility Connections per Approved Civil Plans`
DISRUPTION INFORNIATION
ASSESSED, VALUE: $0„00 PROPERTY AREA; 0
SIDEWALK: ( OXO) DURATION IN MONTHS: 0 FEE: WOO STREET DISRUPTION TRENCH CUT:. ( 0 X 0) :-
PARKING: ( 0X0') DURATION IN MONTHS: 0 FEE: $0,00 YEAR OF OVERLAY: 0 FEE: $0,00
ALLEY 0X0 DURATION IN MONTHS: 0 FEE $0,00
INDEMNITY The Applicant has signed an application which states he/she holds 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 Edmondsor
any ofits departments or employees, including but not limited to the defense ofany legal proceedings including defense costs and
attorney fees by reason ofgranting this permit.
THE CONTRACTOR' IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FORA PERIOD OFONEYEAR FOLLOWING THE FINAL
INSPECTION AND ACCEPTANCE 0 F THEWORK.
• 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 trainingin their
possesion`.
• Restoration is to be in accordance with City codes. All street -cut trench work shall be patched with asphalt or City approved
material prior to the end of the workday- NO EXCEPTIONS.
• Three sets of construction drawings of proposed work are required with the pen -nit application.
CALL DIALrA-DIG (1-800-424-5555) BEFORE ANY EXCAVATION
CALL FOR INSPECTION (425) 771-0220.EXT. 1326
24 HOUR NOTICERIZUIRED FOR ALL INSPECTION REQUESTS'
THIS APPLICATION
ABY THE CITY ENGINEER OR HIS/HER DEPUTY
SPACE PROVIDED„
FAW
ARE PAID, AND RECEIPTIS ACKNOWLEDGED IN
Printed, Fri(IM, June 09, 2017
EJ FILE COPY INSPECTOR COPY F APPLICANT COPY
_4 OV EDA -It -1.
ROW PERMIT NO.: ENG
ISSUE DATE:
RIGHT-OF-WAY C NS C I N
INC, I S90 PERMIT APPLICATION
PROJECT NAME: CONTACT: t
CONTRACTOR:' Phone #•
Mailing Address:
State License #•.
® th Oa C3
City Business License #: j
Fax #:
Email
l.,iawnty Insurance�Rondcd _
ADDRESS OR INTERSECTION OF CONST InJCTI N:
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
EA�N�YASSOCIATED PERMITS? BLD#
DESCRIPTION OF PROPOSED WORK (Be Specific) :
Traffic Control (Only)
ENG#,____
WAS STREET OVERLAYED WITHIN THE LAST FIVES YEARS? YES NO0 Year:
PAVEMENT CUT:, Yes ElNo
CONCRETE CUT: ❑ Yes No
If yes, indicate size of cut. - ID, -_
If yes, indicate size of cut: x...,_
PS!idewalk
T-OF-WAY DURATION
AREA TOTAL
OSURE (NUMBER OF MONTHS)
48 Hrs + LF XLF SF
Alley 72 Hrs + LF X LF SF
w—Parking
..72 Hrs + t.. LF X.LF
..... SF
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 anist 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 statemenmo)'Alrtl�.
ttliderst, nd the permit requirements and acknowledge that I must
follow all requirements m era�it to be valid.
' n
q � � ��..
SIGNATURE DATE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE