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ROW PERMIT NO.: ENG
ISSUE DATE:
RIGHT-OF-WAY CONSTRUCTION
PERMIT APPLICATION
PROJECT NAME0, 4 i �a' � "� CONTACT: �y� ���� yr14
CONTRACTOR: / _ P S �L / Phone #: 2 2 -3 Z
Mailing Address: p U t�} /U� y �r/i.✓�i%/ Fax #:
State License #: Te&77 Email #: pe
City Business License #: ❑ Liabi/lity Insurance Lff Bonded
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ADDRESS OR INTERSECTION OF CONSTRUCTION: �p�H r,• „� ,22}/
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 Job Number
ANY ASSOCIATED PERMITS? BLD# nLNZ1>1Y dP 22 ENG#
Traffic Control (Only)
DESCRIPTION OF PROPOSED WORK (Be Specific) : �� p9,e Arm^ �y
L4.i c./ r- f/D
Z' d w, loft
WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES NO Year:
PAVEMENT CUT: ❑ Yes 'H�Zo
0 If yes, indicate size of cut: x
CONCRETE CUT: 0 Yes If yes, indicate size of cut: x
RIGHT-OF-WAY
DURATION
AREA
TOTAL
CLOSURE
(NUMBER OF MONTHS)
Sidewalk 48 Hrs + LF
X
LF
SF
Alley 72 Hrs + LF
X
LF
SF
Parking 72 Hrs + LF
X
LF
SF
A PPLIC A T TO READ ANT c7rXT
vr11 i 10 Al\lJ A71<Tl\
*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 iniuries, 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 d understand the permit requirements and acknowledge that I must
follow all requirements in er or the permit to be va
SIGNATURE DATE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE