ROW permit application.pdfRANS
I Im
mom
ROW PERMIT NO.: ENQ
ISSUE DATE:
PROJECT NAME: r �� F
TACT.
AACTOR-
Phone
.. ........
fq—aiiinj Addr". -v 1AFai#. fq, 4_1
State LC)L&c (> icense m
Eail #:
.............
P K
P 11"
City Business License fs: M-i"i'a"bility Insurance onded
ADDRESS OR INTERSECTION OF CONSTRUCTION, 54""'-' L
NM MIA
law
I 10 0 Md &110
,Ira#
Multi- FamilySingle Family
tA [:] Other
El EUC (PUD, VFRIZON, PSE,
COMCAST, ONrWSD):
Is this permit part of a blanket permit? Yes No
[��A�SSOC�IATE�DPE�RMIT�_S? ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific): �A)Q.4t'*-
- - -----------
WAS STREET OVERLAYED
PAVEMENT CUT: El Yes No
CONCRETE CLIT: El Yes No
d 00t.8 __ GEL- EEe
TRE LAST FIVE (5) YEARS? YES
If ym indicate size of cut:
If yes, indicate size of cut.
N
x
w[joil"11 .110c! 01 Uel:`
4-o 41,. 4,3 e0k
-31,+ j;,
-f-
0�
WAS STREET OVERLAYED
PAVEMENT CUT: El Yes No
CONCRETE CLIT: El Yes No
d 00t.8 __ GEL- EEe
TRE LAST FIVE (5) YEARS? YES
If ym indicate size of cut:
If yes, indicate size of cut.
N
x
w[joil"11 .110c! 01 Uel:`
RIGHT-OF-WAY 'RATION
C , LOSURE AREA TOTAL (NUMBER OF MONTHS)
D( TION
AR;fA' OF M(
(N jLM jBER )N`1
Si(fewalk 48 ffrs + 1r X
LF X LF SF
Alley 72 Hrs + LF X LF SF
. . ........ . ... . .. .... ...
Parking 72 Hrs LF X LF E= JSF . .. . .......
. .......... . . INS OWN I
APPLICANT TO READND SIGN
*Traffic control and public safety shall be in accordance with City regulations as required by the City
Fligineen Every flagger must be trained as required by (WAC) 296-155-305and must have certification
verifying completion of the required to in their possession.
*Restoration is to be in accordance vvith City codes and Standards. All street -cut trench "or k shall be
patched with asphalt or City approved material prior to the end of the workday, ,'"HCl EXCEPTIONS.
IndOmnitY The Applicant has signed an application which states helshe 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 daTT-aqrqtmWenfftWs oorram�c 6;zj tyw-&",rt
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 lor the permit to bc valid,
SIGNATURE DATE
Contractor AgeAt
NO WORK SHALL 13EGIN PRIOR TO PERMIT ISSUANCE
2 - J D 0 1�1 0 -- (.I C L. -- C a W U 0 �, : I T c" 1 0 a 2 Ir U e C