EPO2 ROW Permit Application.pdfm
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ROW PERMIT NO.: ENG
ISSUE DATE:
0 v �
PROJECT NAME:
CONTRACTOR: 'Li, c,
Mailing Address:
, 4
State License #:
City Business License 4: 0/
CONTACT:,A)"(
Phone77 1 1 'N --7 �,
......................
Email #:
Liability Insurance Bonde(P
,
ADDRESS OR INTERSECTION OFCONSTRUCTION: zo/ I j /-
I ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT: I
Commercial
r-1 Multi -Family
Subdivision
❑ Single Family
F] EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket pet -mit?
City Project
El Other
R Yes El No Job NUmber
I ANY ASSOCIATED PERMITS'? ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific): ftu
< 7
Traffic Control (Only)
Id /4-1,A1 I /A
I WAS STREET OVERLAYED WITHIN THE LAST FIVE._(-�,YEARS? YES E] NO Year:
PAVEMENT CI V] Yes r-1 No If Yes, indicate size of cut: x
CONCRETE CUT: 0 Yes F] No If Yes, indicate size of cut: x
RIGHT-OF-WAY
AREA
CLOSURE
TOTAL
DURATION
(NUMBER OF MONTHS)
Sidewalk 48 Hrs + LF
X
2� 4 LF
l (� SF
Alley 72 Hrs + LF
X
LF
SF
Parking 72 Hrs + 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 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.
INDEMITY: 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 fly reason 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 _ 1 -7- t
or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE