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REVIEWED-ROW APP^lam ., RIGHT OF WAY CONSTRUCTION PERMIT APPLICATION Complete and ,submit this Application in accordance with the Submittal Requirements outlined in kighi-of-Wav permit Haag doui 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 Project Name %' T �yu)� dolitE [ Site Address or if no site address use Property Address at NW corner of project area: Associated Permits: BLDZC�L/ b 00PLN ENG x Name of Campany Franchise Ordinance No: Point of Contact Title Address City A State N/i" Zip A/A Phone Email P • Name of Company ® [ Primary Name Agent Name r-3'- Title rrA Title owlvew Mobile Address IZn /V 777" j-r, 1 Email tv, e . City I State A_I Zip D Secondary Name / Phone t3 i r / Title FAnail Ke_• r—D Mobile A City of Edmonds Business License IM. T 66ips e Email State License No: K�i� Cp C � C M Contractor verifies it is currently b� bonded Co ntractor v Ties it currently has general liability insurance NOTE. ECDC18, 6o.o2o requires th6t the Application be signed by a hlcensM and bonded contractor unless otherwise approved by the city engineer. )(Multifamily residential ❑ Commercial ❑ City project ❑ Single family residential subdivision © Single family -other n Industrial .Demo and rebuild or from vacant land? o Other, please specify: ❑ Utility Franchise Work associated With development (check one of the above boxes as weld a 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.) RIGHT-OF-WAY CLOSURE AREA TOTAL DURATION (Number of Months) Sidewalk 72 hours + &ALF x LF SF Alley 72 hours + IV14 LF x LF SF Parking 72 hours + LF x LF SF SECTION B - If you are not a utility company performing work in the City ROW, skip to SECTION C. 1. The work in the right of way is on or for the following type of facilities: a telecommunications o cable ❑ power o gas a water o sewer © storm Details of WoiI to be Completed 1. Does the utility owner have existin overhead infrastructure in the area of work? Yes IN, o 2. Will any equipment be added unde ound or above ground e.. pedestals, vaults, etc.)? If yes, describe: 3. Does the proposed work connect a lot or commercial development with utilities that serve more than one lot or commercial development? 4. Does the work involve rebuilding or relocating an existing aboveground utility system which connects a lot or commercial development to an existing uncle ound common utility stem. 5. Does the work involve proposed additions to an aboveground utility stem? If es: Are the additions for the purpose of serving new commercial development? Are the additions for the purpose of serving a single-family residential subdivision? Details of • 6. Does your project involve rebuilding or replacing utility equipment which currently serves more than one lot or commercial development? If yes, answer the following questions related to project area, i.e. the actual area in which the ro'ectis ro sed: 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-nipy poles are existing in the ro ect area? What is the height of the existing poles? How many Lples. are to be removed? Are additional poles to be laced? How many? I I What is the 4t!kht of the additionalpoles? 6c. Are any poles to be modified/rebuilt/replaced? If yes: 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 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 an 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 i APPLICANT SIGNATUI APPLICANT PRINTED APPLICANT TITLE: NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE is6'dq-ZP City of Edmonds ROW construction permit Application --Page 3 of 3 Updated 3/25/2021