ROW.pdfINI 50
RECA.,
1 11 76
�(YA
PF31NIVT ENG,
ISSUIT DATE,,,
It IGI IT -OF -)VA, "k" C,"()NST1,,t,1 IC"[W)N
PIMMU!" APPUCATJON,v�
"U &—Cpy�r �6znwag
(N-)F141J4,1-A,MCT'()1), Whe -m
Fax H"
MH No
F,
V2, 7W
'01.ii oncleo
70 .... ...... ...
ADDRESS OR INTERSEMICIP4 OF MMSTRUCTION., 21115" SAvg W
..... ... ...... .
R(M/ WORK ASS0(AA,TFJ WITH THE ITOLLOWIN-C,''I"YPE 01TPR(')XV,CT-
["'] mwti-vainvil[Hy, ["] Single Fan-Ifly ['�'] oawr
DESCRIFF1011 M"PROPOSSI) WOW-( (Be Specific) ,
A t- --:- E-jk* -(— ---, -
YEARS? VE
PAVEMIM CUT Ell Yes i ps iryrs, KUM she d md:
(MMEW CITV [:] Yes Nei If yeq indknte she of cut
APPLICANT TO F AND
*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 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
of granting this permit,
1 have read the above statements and understand the permit requirements and acknowledge that I must
follow all requirements in order for the permit to be valid.
SIGNATURE v f--tt Ut DATE C9I2-'ll `f
Contractor or Agent