ENG2022-0105+City_Application+3.13.2022_8.22.13_AM+2734173RIGHT OF WAY CONSTRUCTION
PERMIT APPLICATION
Complete and submit this Application in accordance with the Submittal
Requirements outlined in Right -of -Way permit Handout E6�.
If any field is not applicable to your project, write "N/A' instead of leaving blank.
All fields required. Incomplete Applications will be denied.
SECTION A
General•
Project Name 7315 212th St SW
Site Address or if no site address use Property Address at NW corner of project area: 7315 212th St SW Edmonds, WA 98026
Associated Permits: BLD PLN ENG
Owner and Entity Holding Franchise (if applicable)
Name of Company Centurlink (Lumen -National) Franchise Ordinance No:
Point of Contact Tracey Tipton
Title Network Implementation Program Manager
Address 22817 SE Issaquah -Fall City Rd
City Issaquah
State WA
Zip 98027
Phone 206-947-9370
Email tracey.tipton@lumen.com
Contractor and Authorized Agent of Owner
Name of Company North Sky Communication
(see note below)
Contractor Contacts During Construction
Primary Name
Agent Name Rob Dautrich
Title
Title Supervisor
Mobile
Address 11818 SE Mill Plain Blvd Suite 302
Email
City Vancouver
State WA
Zip98687
Secondary Name
Phone 253-204-5024
Title
Email rdautrich@northskycomm.com
Mobile
City of Edmonds Business License No: On File
Email
State License No:
NORTHSC857Q4
o Contractor verifies it is currently bonded
0 Contractor verifies it currently has general liability insurance
NOTE: ECDC18.6o.o2o requires that the Application be signed by a licensed and bonded contractor unless otherwise approved by the city
engineer.
❑ Multifamily residential ❑ Commercial ❑ City project
❑ Single family residential subdivision ❑ Single family -other ❑ Industrial
❑ Demo and rebuild or from vacant land?
❑ Other, please specify:
❑ Utility Franchise Work associated with development (check one of the above boxes as welt
❑ Traffic Control Only (no associated development)
• Utility Franchise Work (no associated development)
City of Edmonds ROW construction permit Application --Page i of 3 Updated 3/25/2021
Include an overall narrative description of the proposed work. Be specific and detailed:
Describe infrastructure to be impacted, such as, poles, wires, conduit, utility mains, etc.
Include whether this is construction, maintenance, or repair.
Include description of proposed construction methods, (e.g., bores, trenches, overhead wires proposed, depth for
underground utilities, etc.)
Permit is to re -apply for an expired permit. There will be no changes to the previous scope of work. Previous permit # is ENG2020-0368.
Centurylink proposes remove and replace (1)-2'x4' section of asphalt and (2)-7'x7' flags of sidewalk to bore 1,741' and place (1)-2" conduit with fiber optic cable and place (2)-25TA
vaults within the City of Edmonds ROW.
RIGHT-OF-WAY
CLOSURE
AREA
TOTAL
DURATION
(Number of Months)
Sidewalk '72hours +
LF
I x
LF
SF
Alley'72 hours +
LF
Ix
I LF
SF
Parking 72 hours +
LF
Ix
I LF
SF
SECTION B - If you are not a utility company performing work in the City ROW, skip to SECTIONC.
1. The work in the right of way is on or for the following type of facilities:
e telecommunications ❑ cable ❑ power ❑ gas
❑ water ❑ sewer ❑ storm
Details of • to be Completed
1. Does the utility owner have existing overhead infrastructure in the area of work?
Yes
No
X
2. Will any equipment be added underground or above ground (e.. pedestals, vaults, etc.)?
X
If yes, describe: 1,741' of (1)-2" conduit with fiber optic cable and place (2)-25TA vaults
3.
Does the proposed work connect a lot or commercial development with utilities that serve more
than one lot or commercial development?
X
4.
Does the work involve rebuilding or relocating an existing aboveground utility system which
connects a lot or commercial development to an existing underground common utility stem?
X
5.
Does the work involve proposed additions to an aboveground utility stem? If es:
X
Are the additions for the purpose of serving new commercial development?
X
Are the additions for the purpose of serving a single-family residential subdivision?
X
Details
of • to be Completed
Yes
No
6.
Does your project involve rebuilding or replacing utility equipment which currently serves more
than one lot or commercial development?
X
If yes, answer the following questions related to project area, i.e. the actual area in which the
project is proposed:
6a.
Does your project involve wires/cables/lines? If yes:
How many are existing? I I How many are to be added?
City of Edmonds ROW construction permit Application --Page 2 of 3 Updated 3/25/2021
6b.
Does your project involve poles? If yes:
How many poles are existing in the project area?
What is the height of the existing poles?
How many poles are to be removed?
Are additional poles to be laced?
How many? I I What is the height of the additionalpoles?
6c.
Are any poles to be modified/rebuilt/replaced? If yes:
X
How many? I I What is the height of the poles after?
Describe the modification rebuild:
SECTION C
Traffic Control and Public Safety. 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. Restoration shall 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.
Insurance. The City may require the owner or contractor to provide proof of insurance acceptable to the City prior to
any permit approval.
Indemnification. The Applicant agrees to defend, indemnify, and hold harmless the City of Edmonds, its officials,
officers, employees, and agents against any injuries, damages, or claims of any kind or description whatsoever,
foreseen or unforeseen, including defense costs and attorney fees, resulting directly or indirectly from any act or
omission of the Applicant, its subcontractors, anyone directly or indirectly employed by them, and anyone for whose
acts or omissions they may be liable, arising out of, related to, or by reason of the granting of this permit; and
specifically including but not limited to all loss by the failure of the Applicant to fully or adequately perform, in any
respect, all authorizations or obligations under the permit. These indemnification requirements shall survive the
expiration, revocation, or termination of any resulting permit approval.
Acceptance of terms, conditions, and requirements. Applicant accepts the terms, conditions, and
requirements set forth in this Application and agrees they apply to any resulting permit and shall comply with them to
the satisfaction of the City Engineer. Applicant further agrees to comply with the conditions listed on the Submittal
Requirements; with all applicable city ordinances, including but not limited to ECDC Title 18; and with all applicable
requirements of state and federal law.
Statement of Applicant. I declare under penalty of perjury under the laws of the State of Washington that: I am a
licensed and bonded contractor; the information provided herein is correct and complete; and I am authorized by
owner to act on its behalf and have authority to bind the owner to this application.
Fees. The Applicant is responsible for all permit fees.
APPLICANT SIGNATURE: Glen F. Williams
APPLICANT PRINTED NAME: Glen Williams (For Tracey Tipton)
APPLICANT TITLE: Operations Manager
OigUly signed by Gi.n F. Williams
D. 2022.03.13 ae:20:W-g]'gg'
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
03/13/2022
City of Edmonds ROW construction permit Application --Page 3 of 3 Updated 3/25/2021