ENG2023-0436+City_Application+8.24.2023_9.58.46_AM+3744839of EDA,,()
RIGHT OF WAY CONSTRUCTION
PERMIT APPLICATION
Complete and submit this Application in accordance with the Submittal
'tic. i g90 Requirements outlined in Right -of -Way permit Handout E6.,I.
If any field is not applicable to your project, Write " NIN' instead of leaving blank.
All fields required. Incomplete Applications will be denied.
SECTION A
rPrqjcct!�a-meSLAC
Site Address or if no site address use Property Address at NW corner of project area: 19515 94M W., Edmon&
Associated Permits: BLD 2023-o623 I
PLN ENG
Name of Company Franchise Ordinance No:
Point of Contact
Title Owner
Address 24113 56th Ave. W.
City Mountlake Terrace State WA Zip 98043
Phone 2 - -206
Email duane@LQH-inc.com
Conti'actoi- and Authorized Agent of Owner
Name of Company Landsverk Quality
(see note below)
Homes, Inc
Contnictoi, Contacts During Construction
Primary Name
Agent Name Duane Landsverk
Title SAME]
Title President
Mobile
Address 24113 56th Ave. W.
Email
City Mountlake Terra
state WA
Zip 98043
Secondary Name
Phone 425-754-2o69
Title
Email duane@LQH-inc.com
Mobile
City of Edmonds Business License No:
Email
State License No: I ANDSQH023JN
❑ XX Contractor verifies it is currently
bonded
❑ XX Contractor verifies it currently has general liability
insurance
NOTE: ECDC r8.6o.02o requires that the Application be signed by a licensed and bonded eortttactrir unless otherwise approved by the city
engineer.
❑ Multifamily residential ❑ Commercial ❑ City project
❑ Single family residential subdivision .0 XX Single family- ❑ Industrial
❑ Demo and rebuild or from vacant land? other
❑ 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 1 of 3 Updated 3/25/2021
❑ Utility Franchise Work (no associated development)
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.
j`sich3de 6V_,m -pion of -proposed roes ruction methods; (e.g., bores; trenches, overhead wires proposed, depth for
underground utilities, etc.)
REPAIRIREPLACEMENT OF A BROKEN SIDE SEWER - NO INFRSTRACTURE TO BE IMPACTED. THE
REPLACEMENT SIDE SEWER WILL BE PLACED IN THE SAME SPACE AS THE EXISTING SIDE SEWER
TRENCH DITCH TO REMOVE OLD SIDE SEWER AND REPLACE WITH A 6' SIDE SEWER
THIS WORK WILL TAKE PLACE IN AN UNOPENED RIGHT OF WAY THAT IS CURRENTLY USED FOR THE SOLE
PURPOSE OF ACCESSING ONE SINGLE FAMILY RESIDENCE THAT BELONGS TO THE APPLICANT
RIGHT-OF-WAY
CLOSURE
AREA
TOTAL
DURATION
(Number of Months)
Sidewalk 72 hours +
LF
x
LF
Alley�72 hours +
LF
x
LF
SF
Parkin 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.
Type 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
1. 1 Does the utility owner have existing overhead infrastructure in the area of work?
X-
2. 1 Will any equipment be added underground 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 underground common utility system?
5.
Does the work involve proposed additions to an aboveground utilitysystem? 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?
6. IDoes your project involve rebuilding or replacing utility equipment which currently serves more k
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, Le_ the actual area in which the
project is proposed:
6a.
Does your project involve wires/cables/lines? If yes:
Al
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 many? What is the height of the additional oles?
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 fiagger must be trained as requiredbv 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 inderradfccaftan requiremeabi 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 eonfmclor; 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 f r all permit fees..
APPLICANT SIGNATURE: Z Ca, "a DATE:
APPLICANT PRINTED NAME: ` e SiOM
T'
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