Wardak ROW, Sewer permit AppG~� OF EVtjo �r
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CONTRACTOR INFORMATION:
Company Name:
Company Address:
SIDE SEWER
PERMIT APPLICATION
Site Contact: r —,-
Phone #:
P
City. gyp' � �Z� Lma4l #:
State License # _ 'FLA City Business License #
Expiration Date: 2 _ 2 � _ , to
PROPERTY INFORMATION:
Address:
Owner's Name:
Phone #:
FULL LINE REPLACEMENT ❑ SPOT REPAIR ❑ PIPE BURST ❑ RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific):
ISSUANCE OF THIS PERMIT DOES NOT CONSTITUTE PERMISSION TO WORK ON ANY PROPERTY OTHER
THAN THAT OWNED BY THE SUBJECT PROPERTY OWNER,
CERTIFICATIONS NECESSARY FOR INSTALLATION METHODS ARE THE RESPONSIBILITY OF THE
CONTRACTOR PERFORMING SAID WORK.
I REPRESENT AND WARRANT TO THE CITY OF EDMONDS, IF REPAIR OF EXISTING SEWER EXTENDS TO AN
ADJACENT PROPERTY, I HAVE OWNERS EXPRESS PERMISSION TO PERFORM WORK ON THAT ADJACENT
PROPERTY.
SIGNATURE s DATE J�
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
V1�� pf EDAfa���r
RIGHT OF WAY CONSTRUCTION
PERMIT APPLICATION
Complete and submit this Application in accordance with the Submittal
"vc. 1$a13 Requirements outlined in Right -of -Way ermit 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
Project Name
site Address or if no site address use Property Address at NW corner of project area: �� ` l,z � ��
AssociatedPermits: BLD Zc�� 1t�1 p ENG
Name of Company Primary Name r—�
Agent Name 1l�' Title i
Title + Mobile l� ^ -7
Address pig' 13� 1 r� Email
City Stateu/pA Zip Secondary Name
zece
5 -73 L- Tale
Email f&\V, t S , 6 a � V1 Mobile
City of Edmonds Business License No: _ Email
State License No: ; 0 ( _ IZ4
KContractor verifies it is currently bonded Contractor verifies it currently has general liability insurance
NOTE: ECDCi8.6o_o2o requires that the Application be signed by a licensed and bonded contractor unless otherwise approved by the city
engineer.
Type of Developm ent — Check ALI, that apply
❑ 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 Lcheek one of the above boxes as well
a Traffic Control Only (no associated development)
❑ Utility Franchise Work (no associated development)
City of Edmonds ROW construction permit Application --Page 1 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 AREA TOTAL DURATION
CLOSURE
(Number of Months)
ewalk 72 hours + LF x LF SF
:y 72 hours + x LF SF
kin 2 hours +F.Mu�;�L�F x LF SF
SECTION B - If you are not a utility company performing work in the City ROW, ski to o SECTION C.
Type of Mility Facilities
1. The work in the right of way is on or for the following type of facilities:
❑ telecommunications ❑ cable ❑ power ❑ gas
❑ water n sewer ❑ storm
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
project is nronosed:
6a. I Does your project
How many are
If yes:
How many are to be
City of Edmonds ROW construction permit Application —Page 2 of 3 Updated 3/25/2021
6b. Does your project involve poles? If yes:
How man poles are existing in the pyoject area?
What is the hei ft of the existing poles?
How man.y poles are to be removed?
Are additional oles to be laced?
How many? I What is the hei t of the additionalpoles?
_!._Are any poles to be modified/rebuilt/replaced? If yes:
How many? Wbat is the height of the oIes 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 peripit fees.
APPLICANT SIGNATURE:
APPLICANT PRINTED NAME:
APPLICANT TITLE:
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
City of Edmonds ROW construction permit Application —Page 3 of 3 Updated 3/25/2021