Permit App - SignedL~�
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ROW PERMIT NO.: ENG
ISSUE DATE:
RIGHT-OF-WAY CONSTRUCTION
PERMIT APPLICATION
PROJECT NAME: 12 Q ` Or lo
CONTACT:��
CONTRACTOR: T ev, U �� .�. i Phone #: -1'l
1110
Mailing Address: t,} 4 �� UA F'ax #: I
t r
State License #: I r��_ ti _ �.L Email#:
City Business License #: '1 Liability Insurance Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION:
.M 6
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ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
Commercial U Subdivision ❑ City Project Ll Traffic Control (Only)
❑ Multi -Family 4 Single Family ❑ Other
❑ EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? ❑ Yes ❑ No
ANY ASSOCIATED PERMITS? rBLD,# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific) : __SQR A AC'W _
WAS STREET OVERLAVED WITHIN THE LAST FIVE 5 YEARS? YES F1 NO Year:
PAVEMENT CUT: Yes ❑ No
CONCRETE CUT: Yes ❑ No
If yes, indicate size of cut: a
If yes, indicate size of cut: x
Ri(;II r-OF-WAY
CLOSURE:
AREA
TOTAL,
DURATION
F(NUMBER OF MONTHS)
Sidewalk 48 Ilrs + LF X i
Alley 72 firs +� LF X__
- Parking 72 Mrs + _ LF X
LF
LI�
--- LF
SIB'
S1"
SF
APPLICANT TO READ AND SIGN
*Traffic control and public safety shall be in accordance with City regulations as required by the City
Engineer. Ever) ffagger 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 requirements in order for the permit to be valid,
SIGNATURE DATE Z I
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
[*wrtment of [Abor end Induntnes
Contrimewr Registrelion Swlion
PO Box 44450
Olympm WA 48504-445()
WASHINGTON CONTRACTOR'S LICENSE BOND
VALIDATION RIDER
This rider is part of bond number 72160916 issued to
as
Tien NQuyen dba TNT Landscaoiny Services principal,
effective on May 17th, 2019 . The fact that the effective date of the bond is more than
(effective date of bond)
thirty (30) days prior to the date; it was filed with the Contractor Registration Section shall not make the
bond invalid or unenforceable. However, the bond itself shall be void if the principal does not
file it and this rider with the Contractor Registration Section within thirty (30) days of the
date this rider is issued.
Rider Issued This: 15th day of July, 2019
Bond Comp
WFS- Rt SURETY ANY
sy:
Paul T. Bruflat, Vice President , Attorney -in -Fact
This rider is intended to be used: a) in conjunction with a bond with an effective date of more than
thirty (30) days prior to the date of filing with the Contractor Registration Section; and b) with a bond
issued as a substitute for a previous bond or deposit with the Department of Labor and Industries
where the effective date of the bond is to be more than thirty (30) days prior to the date of filing of the
bond.
F62 5-l)'W000 contractor validation nder 09 M
Western Surety Company
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS:
That WESTERN SURETY COMPANY, a corporation organized and existing under the laws of the State of South Dakota, and
authorized and licensed to do business in the States of Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut,
Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine,
Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey,
New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina,
South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming, and the United
States of America, does hereby make, constitute and appoint
Paul T. Bruflat of Sioux Falls
State of Dilk"La , its regularly elected Vice Presiderit
as Attorney -in -Fact, with full power and authority hereby conferred upon him to sign, execute, acknowledge and deliver for and on
its behalf as Surety and as its act and deed, the following bond.
One Contractors License
bond with bond number __ 7215. 916 _
for
as Principal in the penalty amount not to exceed: $ 12,OOD.00LL
Western Surety Company further certifies that the following Is a true and exact copy of Section 7 of the by-laws of Western Surety Company
duly adopted and now in force, to -wit.
Section 7 All bonds. policies, undertakings, Powers of Attorney, or other obligations of the corporation shall be executed in the corporate
name of the Company by the President, Secretary, any Assistant Secretary, Treasurer, or any Vice President, or by such other officers as the
Board of Directors may authorize The President, any Vice President, Secretary, any Assistant Secretary, or the Treasurer may appoint
Attorneys-m-Fact or agents who shall have authority to issue bonds, policies, or undertakings in the name of the Company The corporate seal is
not necessary for the validity of any bonds, policies, undertakings, Powers of Attorney or other obligations of the corporation. The signature of any
such officer and the corporate seal may be printed by facsimile.
In Witness Whereof, the said WESTERN SURETY COMPANY has caused these presents to be executed by its
Vice Pres i bent with the corporate seal affixed this _1.5t_4_ _ day of
2019
ATTEST WESTE N URET COMPANY
By �...�
L. Nelson, Assistant Secretary Paul T ruflat, Vice Preekkirit
�,atiareuiwrnay
svarrL4,.,,
ORq�; �-
STATE OF SOUTH DAKOTA ' 3 S b A,
COUNTY OF MINNEHAHA !ss
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On this 15th day of July 1 before me, a Notary Public, personally appeared
PaulT. .B�uflat and L. Nelson
who, being by me duly sworn, acknowledged that they signed the above Power of Attorney as Vice President
and Assistant Secretary, respectively, of the said WESTERN SURETY COMPANY, and acknowledged said instrument to be the
voluntary act and deed of said Corporation.
f SS SSSSSSSSSSS4SSSSSSSSSS 1
J. MOHR
r �7l1� 1
i E I NOTARY PUBLIC SEAL i
r�SOUTH DAKOTA�f Notary Public
♦.,yo,..4a...oti4titiSSSSY4SSSSS ♦ t^.y Con-nission Expires June 23, 2021
To validate bond authenticity, go to > Owner/Obligee Services > Validate Bond Coverage.
Form F1975-1.2016