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PROJECT NAME:
-- - - ' I YQ4-hC 'ltt
Mailing Address-4-'b—A?,'-
State License #:
City Business License
CONTACT:
Phone #* w eel/ -
Fax #:
Email #: -7-4v owhos 094d ikm 11 [40 kl--
-0 "Liability beau-raiZe U Bonded
A131,11ESS OR INTERSEMON OF CONSTRUCTION: Pit i A'ew X Ael'w w5
ROW WORK ASSOCIATED WITH THE. FOLLOWING TYPE OF PROJECT:
Commercial Subdivision city Preaject Traffic Control (Only)
❑ Multi -Family ❑ Single Family ❑ Other
L) FUC (PUD, VERIZON, PSE,
COMCAST, OVWSD).-
Ts this permit part of a blanket permit? ED yes No
ANY ASSOCIATED PERMITS? BLD# ENG#.
DESCRIPTION OF PROPOSED WORK (Be Speeffic): 4- in 04— 01A
'4 Wei v P 1'k -Q!LIK r C-X- m zn Ot- IY- -CeeL by I ( -Pee4-,
WAS AV D WITHIN THE LAST FIVE f5) YEARS? YES NO Year:
PAVEMENT CUT: ❑ Yes [A No If yes, indicate size of cut: A
CONCRETE CUT: ❑ Yes L3 No If yes, Indicate size of cut: x
1Ii"T.OF-WAY
CLOSURE AREA TOTAL
4dewailt 4$ Hrs 4- LF X LF
_ SF'
Alley 72 Hrs + LF X LF
_ SF
Parking 72 Hrs + LF X C,F
SF
DURATION -
(NUMBER OF MONTHS)
EA►D 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- t 55-305 and must have
ing
verifying completion of the required trainin their possession. certification
'Restoration is to be in accoronce with City codes and Standards. All patched with asphastreet-cut trench work shall be
li or City approved material prior to the end of the workday — NO EXCEP"TK}NS.
Jrtdentnity The Applicant has signed an application which states he/she hoId the City of
Edmonds harmless itom Injuries, damages or claims of any hind or description
whatsoever, foreseen or unforeseen, that may be made against the City Of Edmonds or
any Of its departments or employees, of grr,�ntfng this permit including defiense costs and attorney fees by reason
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 ,a
M
HATE '?� 6
CatrErxcifet• o . _ -- - _
NO WORD SHALL BEGIN PRIOR TO PERMIT ISSUANCE
rG6vkft0 L
ROW PERMIT NO.: ENC i
ISSUE DATE:
k RIGHT-OF-WAY CONSTRUCTION
PERMIT APPLICATION
PROJECT NAME:
CONTRACTOR: .
�"��Arin
Mailing Address: & --
State License #: -
City Business License #: ...-.-
CONTACT: m, e/
Phone #: 'aX.. &— &-.5
Fax #:
Liability Insurance Banded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 147Z.7.3 0 jWpit 1lt`P6 , a, �
VW_lORK ASSOCIATEDW1TH THE FOLLOWCoercial Subdivis9aq City ProjectTraffic Control (Clnly)
❑ 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#
DESCRIPTION OF PROPOSED WORK (Be Specific):,_ t j � /,q, owA�I
WAS STREET OVERLAYED WITHIN THE LAST FIVE S) YEARS? YES NO Year:
PAVEMENT CUT: ❑ Yes 14 No If yes, indicate size of cut: x
CONCRETE CUT: ❑ Yes 53 No if yes, indicate size of cut:. _ x
RIGHT-®F-WAV
CLOSURE
Sidewalk 48 Hrs +
Alley 72 Hrs +
Parking 72 Hrs +
AREA
LF X LF
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.Applicant has signed an application which states helshe hold the City of
Edmonds harmless from Injuries, damages of
whatsoever, foreseen or unforeseen, that may be made against the City of Edmonds or
one. of
ef granting permit.
I have read the above statements and understand the permit requirements and acknowledge that I mist
follow all requirements in order for the permit to be valid. j
SIGNATURE DATE
Contra tt
�4
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE