ENG2022-0410+City_Application+7.31.2022_6.38.02_AM+3022899Of EDATp�O
s RIGHT OF WAY CONSTRUCTION
PERMIT APPLICATION
Complete and submit this Application in accordance with the Submittal
"NC. F690 Requirements outlined in Right -of -Way.. permit Handout EQ3.
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 Info
Project Name SV IL Al G
Site Address or if no site address use Property Address at NW corner of project area:
Associated Permits: BLD _ L90Cf4 I PLN ENG
Owner and Entity
Name of Company
Holding Franchise
(if pp
Franchise Ordinance No:
Point of Contact
K jG H
V V1 L
Title
V
Address
12 3
LA/
City
E MD NO
State k)A
Zip 9
Phone
269
_ 17 "
Email
✓G (
vaC S ✓G Rat 6a 57.
Contractor and Authorized Agent of O�N tier (see note below)
Name of Company Lf IAl WNS TRUGT AI ZLL
Contractor Contacts
Primary Name
During Construction
icNatev
Agent Name 0 4 C PQ n/G M #4
Title
0W N
Title wN E
Mobile
Z!� _4qq 7 3-I
Address 521 l6 5
Email
i/t�.G 5V
City L Y" JqX % State Zip qg03,7
Secondary Name ti0 MAR
Phone 1125 9 / 434qTitle
CO Al 7,9 A C V -(
Email G yakoo,41
Mobile
2 57 9 3 t 4 3 f
City of Edmonds Businfts License No:
Email
C1!„ i.G tt G Q
�Ci
State License No: CC OL 2J2
Contractor verifies it is currently bonded
Cl/ Contractor verifies it currently has general liability insurance
NU"I E: ECVC 18.60.020 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 VSingle 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 well)
❑ Traffic Control Only (no associated development)
City of Edmonds ROW construction permit Application --Page i of 3 Updated 3/25/2021
00
❑ Utility Franchise Work (no associated development)
Inciude 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.)
,1k D
RIGHT-OF-WAY
CLOSURE
AREA
TOTAL
DURATION
(Number of Months)
Sidewalk 72 hours +
LFTx_T
LF
SF
A/111
Alley 72 hours +
LFTxT
LF
SF
/V /4
Parking 72 hours +
LF
JxJ
LF
I SF
AIM
SECTION B - If you are not a utility company performing work in the City ROW, skip to SECTIONC.
Yype of Utility Facilities
1. The work in the right of way is on or for the following type of facilities:
❑ telecommunications ❑ cable ❑ power ❑ gas
&water ❑ sewer ❑ storm
Details Work to be Completed
of
t. 1 Does the utility owner have existing overhead infrastructure in the area of work?
Y(-�
No
2. 1 Will any equipment be added underground or above ground (e.g. pedestals, vaults, etc.)?
Jc
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?
k
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?
X
5.
Does the work involve proposed additions to an aboveground utility system? If es:
X
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 Work to be Completed � t'� No
6. 1Does your project involve rebuilding or replacing utility equipment which currently serves more
than one lot or commercial development?
City of Edmonds ROW construction permit Application --Page 2 of 3 Updated 3/25/2021
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?
6b.
I 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 man? I I What is the height 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
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 own to this application.
Fees. The Applicant is responsible for all permi s.
APPLICANT SIGNATURE: DATE: 7 Z 0?
APPLICANT PRINTED NAME: KO1v S T A k 7- l Al 5 A/3 % Eli
APPLICANT TITLE: / T
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
City of Edmonds ROW construction permit Application --Page 3 of 3 Updated 3/25/2021