Right of Way Application.pdfi �4
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ROW PERMIT NO.: ENO
ISSUE DATE:
ROW WORK ASSOCIATED ED . WITH THE � FOLLO O TYPE OF PROJECT:
Commercial Subdivision City Project Traffic control (Only)
❑ Multi -Family ❑ Single Family ❑ Other
❑ EUC (PUD, VERIZON, PSE, RECEIVED
COMCAST, OVWSDI Jow0 7' 2016
Is this permit part of a blanket permit? ❑ Yes ❑ No
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ANY ASSOCIATED PERMITS? BLD# ENG#,
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DESCRIPTION OF PROPOSED WO (Be Specific) ZV1Satc. \ QM �W1 tz
WAS STREET OVERLAYED WITHIN THE, LAST FIFE (5) BARS? YES I__.I NO JJ1 Year:
PAVEMENT CUT: 0 Yes F]No If yes, indicate size of cut: X,
CONCRETE CUT: E] Yes 0 No If yes, indicate size of cut: x
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PROJECT NAtc����S
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CONTACT: r
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CO"T CTOR:
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Phone #:
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Fax #:
State License #:
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Liability Insurance
City Business License #:
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ROW WORK ASSOCIATED ED . WITH THE � FOLLO O TYPE OF PROJECT:
Commercial Subdivision City Project Traffic control (Only)
❑ Multi -Family ❑ Single Family ❑ Other
❑ EUC (PUD, VERIZON, PSE, RECEIVED
COMCAST, OVWSDI Jow0 7' 2016
Is this permit part of a blanket permit? ❑ Yes ❑ No
%wr-4,or.At pIVIS100
ANY ASSOCIATED PERMITS? BLD# ENG#,
-f �O Zbl 500q:.5
DESCRIPTION OF PROPOSED WO (Be Specific) ZV1Satc. \ QM �W1 tz
WAS STREET OVERLAYED WITHIN THE, LAST FIFE (5) BARS? YES I__.I NO JJ1 Year:
PAVEMENT CUT: 0 Yes F]No If yes, indicate size of cut: X,
CONCRETE CUT: E] Yes 0 No If yes, indicate size of cut: x
RIGHT-OF-WAY DURATION
AREA TOTAL
CLOSURE (NUMBER OF MONTHS)
Sidewalk 48 Hrs + LF X LF SF
.... Alley72 _.�_.,.__ .... ... ....m ....
Hrs + LF X LF SF
..... �, Parlan
g 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.
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 statements and understand the permit requirements and acknowledge that I must
follow all regriirementsVin rd r for the it to be valid.
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SIGNATURE '� x DA �
! ont actor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE