Maldayzs city of Edmonds ROWSS.pdfCONTRACTOR INFORMATIQN:
Company Name: AvA Ovin,� Pe -
Company Address:
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City: Zip: ciseO21�
State License # AVA Hotli- T%l
Expiration Date:
1
Site Contact: L)etdace-
Phone #:
Email #:
City Business License #
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Address: 01
19130 1 nirl VR e LJ bem 'E"AAl c,,9,
Owner's Name: I s so
Phone #: - -j
ULL LINE REPLACEMENT [I SPOT REPAIR [I PIPE BURST 0 RELINE (PER MALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific):
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e 6oj,,ner 61, W1
ISSUANCE OF THIS PERMIT DOES NOT CONSTITUTE PERMISSION TO WORK ON ANY PROPERTY OTHER
THAN THAT OWNED BY THE SUBJECT PROPERTY OWNER,
CERTIFICATIONS NECESSARY FOR INSTALLATION METHODS ARE THE RESPONSIBILITY OF THE
CONTRACTOR PERFORMING SAID WORK.
I REPRESENT AND WARRANT TO THE CITY OF EDMONDS, IF REPAIR OF EXISTING SEWER EXTENDS TO AN
ADJACENT PROPERTY, I HAVE OWNERS EXPRESS PERMISSION TO PERFORM WORK ON THAT ADJACENT
PROPERTY. bZ tt),Oti —
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SIGNATURE DATE
Contractor or Agent
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EUGHT-OF-WAY CONSTRUCTION
rERMIT APPLICATION
PROJECT NAME:
CONTRACTOR: Pe
ALIA
Mailing Address:
&330
State License #-
AVA
City Business License #: kip, — 6'� 5-S, 2-C,
CONTACT:
Phone#:
Fax #:
Email #: a ve, ke'vhes Ile, , ee;4',
-5&Liability Insurance 0 Bonded
OF CONSTRUCTION:
I
F] EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
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ANY ASSOCIATED PERMITS?
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jMIN i"11110"', �1' "'K W—v
PAVEMENT CUT: [V Yes F1 No
CONCRETE CUT: n Yes 0 No
If yes, indicate size of
aga
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. I
*Restoration is to be in accordance with City codes and Standards. All street -cut trench work shall
patched with asphalt or City approved material prior to the end of the workday — NO EX
of granting this permit.
I have read the above statements and understand the permit requirements and acknowledge that I must
follow all requirempts *;i order for the permit to be valid.
SIGNATURE DATE
Contractor or Agent 1 7—