ENG2022-0045+City Application+2.4.2022_9.49.15_AM+2661775of Ecs,4a
RIGHT OF WAY CONSTRUCTION
A`` PERMIT APPLICATION
Complete and submit this Application in accordance with the Submittal
I Requirements outlined in Right-of-way permit_Handout E63
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 3!`f U oti ., . ,.. Vo
Site Address or if no site address use Property Address at NW corner of project area:
Associated Permits: I BLia _ Z 3 PLN ENG
Name of Company
Point of Contact
Title
'4;,tlJ d �' � � V _ Franchise Ordinance No:
Z -3 K ' ® 6g
N (?wL
Address / 1
VS
City ' cep
State
Zip
Phone 6
G -
Email
r
U
Name of Company
Primary Name
Agent Name
Tide Q CV
Title JN
Mobile ',7Q 6, l0
Address 7 F
IV (F
Email
City 5'
State
Zip
p' ��c�
Secondary Name
Phone �� ®
Title
Email
r
Mobile
City of RtYrnonds Business 00ense No.
Email
State License No: f1 /,_
li
Contractor verifies it is currently bonded
Contractor verifies it currently has general liability insurance
NO E: ECLD:18.6o. o2o requires that theApplicatton be signed by a licensed and bonded contractor artless 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 (cheek one -of the above boxes - ureil)
❑ Traffic Control Only (no associated development)
• Utility Franchise Work (no associated development)
City of Edmonds ROW construction permit Application --Page > of 3 Updated 3/2r/2021
incmoe 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 +
LF
x
LF
SF
Alley 72 hours +
LF
x
LF
SF
Parkin hours +
LF
x
LF
SF
SECTION B - If you are not a utility company performing work in the City ROW, &J012 to SECTIONC.
1. The work in the right of way is on or for
❑ telecommunications ❑ cable
❑ water ❑ sewer
❑ power
Q storm
❑ gas N17/ -
1. Does the utility owner have existing -overhead infrastructure in the area of work?
/
2. 1 Will any equipment be added underground or above ground e.. pedestals, vaults etc.)? —
If yes, describe:
3.
Does the proposed work conned a lot or commercial development with utilities that serve more
than one lot or commercial development?
LI/
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 system?
5.
Does the work involve proposed additions to an aboveground utility system? If
i/
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 NVoik to be Coilipleted
Yes
6.
Does your project involve rebuilding or replacing utility equipment which currently serves more
N7
than one lot or commercial development?
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:
L /
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 es are existing in the project area?
What is the height of the existing poles?
How many poles are to be removed?
Are additional les to be placedl
How many? What is the height of the additionalpoles?
6c.
Are any poles to be modified/rebuilt/replaced? If yes:
V
How many? I I What is the height of the poles after?
Describe the modification rebuild:
SECTION C
'rrattic 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:
APPLICANT PRINTED NAME:
APPLICANT TITLE:
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE' I � � 2 2
City of Edmonds ROW construction permit Application --Page 3 of 3 Updated 3/25/2o2i