ENG2023-0383+City_Application+7.26.2023_1.04.24_PM+3690355DocuSign Envelope ID: 5C2A7DFD-OOF6-4415-B670-905B1016B239
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RIGHT OF WAY CONSTRUCTION
PERMIT APPLICATION
Complete and submit this Application in accordance with the Submittal
hvc. Imo Requirements outlined in Right -of -Way permit Handout E6 t.
If any field is not applicable to your project, write "N/A" instead of leaNring blank.
All fields required. Incomplete Applications will be denied.
SECTION A
Name of Company Franchise Ordinance No: ^!
Point of Contact
Title19
�V
Address,C—
City ��. l..O y State 111 zip m2cZ '
Phone
Email
I/
MMMMEENEM
Name of Company 4% OekL •`
PrimaryName 10,4zlAolfee
Agent Name k .
Title Qbvll-e-"
Title
Mobile A . 73 O -
Address Z �/I
Email �, !
City State k1A Zip '$ t
Secondary Name ♦ . t
Phone
Z
Title �
Email 1. I�
Mobile Z 1
City of Edmonds Business License No: - C 3
Email
State License No:
Contractor verifies it is currently bonded Contractor verifies it currently has general liability insurance
_A „ 1—c nthorm se annroued bu the city
NOTE: ECDC 18,60.020 requires that the: tppiicanon oe signed by u Mu„u .,
engineer.
Twe of Development — Check ALI, that apply
Multifamily residential ❑ Commercial ❑ City project
❑ Single family residential subdivision Single family -other o Industrial
❑ Demo and rebuild or from vacant land?
❑ Other, please specify:
❑ Utility Franchise Work associated with development (check one of the above boxes as well)
❑ Traffic Control Only (no associated development)
City of Edmonds ROW construction permit Application --Page i of 3 Updated 3/25/2027
DocuSign Envelope ID: 5C2A7DFD-OOF6-4415-B670-905B1016B239
❑ Utility Franchise Work (no associated development)
incmae an overau narrative uescnpuon U1 U. JJAVP .— ••�•�- �r----•-- - -- ------ -
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
All z hours +
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, skin to SECTIONC.
i. The work in the right of way is on or for the following type of facilities::
❑ telecommunications ❑ cable a power o gas
❑ water ❑ sewer )(storm
t. Does the utility owner have eAstin overhead infrastructure in the area of work?
2. Will an equipment be added underground or above round e.. pedestals,vaults etc.)?
If es describe:
3.
Does the proposed work connect a lot or commercial development with utilities that serve more
X
than one lot or commercial development?
Does the work involve rebuilding or relocating an existing aboveground utility system which
X
q.
connects a lot or commercial development to an existin underground common utility system?
Does the work involve proposed additions to an aboveground utility system? If es:
K
5.
Are the additions for the purpose of serving new commercial development?
✓
Are the additions for the purpose of serving a single-family residential subdivision?
IT
Yes No
771, of Work to be Completed
6 Does your project involve rebuilding or replacing utility equipment which currently serves more X
than one lot or commercial development?
City of Edmonds ROW construction permit Application --Page 2 of 3 Updated 3/25/2021
DocuSign Envelope ID: 5C2A7DFD-OOF6-4415-B670-905B1016B239
If yes, answer the following questions related to project area, i.e. the actual area in which the
NA
project is proposed,
%1
6a. Does your project involve wires/cables/lines? If yes:
How man a1•e existin ? How man are to be added?
N
611. Does your project involve poles? If yes:
X
How man oles are ex s ng in the pro'ect area?
A
NA
What is the height of the existingpoles?
U
How man oles are to be removed?
A
Are additional poles to be laced?
is hei ht the additional oles?
R
How man What the of
6c.
Are any poles to be modified/rebuilt/replaced? If yes:
X
How many? I What is the hei ht of the poles after?
w
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.
07/25/2023
APPLICANT SIGNATURE: 1"�"! ""'I DATE:
APPLICANT PRINTED NAME: JA4k L 4Lt4!t., O w M✓
APPLICANT TITLE: _..O 1/
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
City of Edmonds ROW construction permit Application --Page 3 of 3 Updated 3/25/2021