20130729121122832.pdf_1 OF EDA,1n,
INC. i S911
PROJECT NAME:
ROW PERMIT NO.: ENG
ISSUE DATE: -7 7y i3)
CONTRACTOR: e 6"k -Q.
Mailing Address:
State License #: c
C,
City Business License #:
CONTACT: —, \ (I
Phone #:
Fax #:
Email #. E I A
–r—Liability insurance F-1 Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION:
Commercial
E] Multi -Family
Subdivision
[:1 Single Family
F E UC (PUD, VERIZON, PSI,,
COMCAST, OVWSD):
Is this permit part of a blanket permit?
City Project
F] Yes D No
Traffic Control (Only)
� ANY ASSOCIATED PERMITS? I � BLD# Q J!, -- 0 �2 �' ENG#,,9(31S - 03�G 1
DESCRIPTION OF PROPOSED WORK (Be Specific):
,A
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES F] NOE] Year:
PAVEMENT CUT: [T Yes E] No If yes, indicate size of cut: '17 0 x
CONCRETE CUT: F-1 Yes F-1 No If yes, indicate size of cut: X...
RIGHT-OF-WAY DURATION
AREA TOTAL
CLOSURE (NUMBER OF MONTHS)
Sidewalk 48 Hrs + LF X LF C, SF '12–
Alley 72 Hrs + LF X LF SF
Parking 72 Hrs + LF X LF SF
APPLICANT TO READ AND SIGN
*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 is to 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.
Indemnity: The Applicant has signed an application which states he/she hold the City of
Edmonds harmless from injuries, damages or claims of any kind or description
whatsoever, foreseen or unforeseen, that may be made against the City of Edmonds or
any of its departments or employees, including defense costs and attorney fees by reason
of granting this permit.
I have read the above statements and understand the permit requirements and acknowledge that I must
follow all requirements in order for the permit to be valid.
SIGNATURE )( 1—IT-1 � DATE_1J;LLZ1
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE