ROW permit application.pdfCity of Edmonds Permit No:
RIGHT-OF-WAY CONSTRUCTION PERMIT Issue Date:
A. Address or Vicinity of Construction: ;Lo ( S . ye— J
B. Type of Work (be specific): �P �Jv�n wit SS i t�.� O e- 4600 !iO- tto ^ U. f=c5 R"
C. Contractor: F—_e l (o
Mailing Address: Y'Q f /� C
State License #: FI (GOG I l c)-Zo k u
City Business License #: 0 P,` C) I )' Lf 6 f
Contact: �Cgec, l71/GQ+'�
Phone: 'Nx - q K(?
Liability Insurance: a M Bond: $ K
D. Building Permit # (if applicable): Side Sewer Permit # (if applicable):
E. 1;9� Commercial ❑ Subdivision ❑ City Project ❑ EUC (PUD, VERIZON, PSE, COMCAST, OVWSD)
❑ Multi -Family ❑ Single Family ❑ Other
INSPECTOR:
F. PAVEMENT CUT: ❑ YES NO G. SIZE OF CUT
CONCRETE CUT: ❑ YES NO
G. ❑ Mail Approved Permit V] Call for Pickup
INDEMNITY. • Applicant understands by his/her signature to this application he/she holds 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 but not limited to the defense of any legal proceedings including defense
costs and attorney fees by reason of granting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL
INSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREET PATCH IS
COMPLETED BY CITY FORCES, AT WHICH TIME A DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT.
♦ 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. All street -cut trench work shall be patched with asphalt or City -
approved material prior to the end of the workday - NO EXCEPTIONS.
♦ Three sets of construction drawings of proposed work are required with the permit application.
CALL DIAL -A -DIG (1-800-424-5555) PRIOR TO BEGINNING WORK
I HAVE READ THE ABOVE STATEMENTS AND UNDERSTAND THE PERMIT REQUIREMENTS AND ACKNOWLEDGE
THAT I MUST E T=INKCF THE PERMIT AVAILABLE ON SITE AT ALL TIMES FO5R^INSPcE�CTIONS
Signature: Date: o _ -, 0 u
(Contractor or Agent)
FOR CITY USE ONLY
Approved by:
Time Authorized: Void After
Special Conditions:
REQUIRED INSPECTIONS:
Right-of-way Fee:
Disruption Fee/Fund 111:
Inspection Fee:
Total Fee:
Receipt No:
Issued by:
Call 425-771-0220, Ext. 1326 for a 24-hour voice -recorded inspection request line.
FINAL APPROVAL OF PERMITTED WORK: DATE:
NO WORK SHALL BEGIN PRIOR'f0 PERNIIT ISSI;ANCE
Revised 10/01/03
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