20140723145523510.pdf'_T OV- EDAyr).
ISSUE DATE:
PROJECT NAME: CONTACT:
CONTRACTOR:, Phone #:
Mailing Address: Fax #:
State License #: Email #:
City Business License #: El Liability Insurance Llj Bonded
[:] Multi -Family
Subdivision
Single Family
F-1 EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit?
City Project
0
El Yes El No Jab Number
ANY ASSOCIATED PERMITS? BLD# ENG4
DESCRIPTION OF PROPOSED WORK (Be Specific):
Traffic Control (Only)
PAVEMENT CUT: 0 Yes El No If yes, indicate size of cut: _x
CONCRETE CUT: El Yes El No If yes, indicate size of I..... . ........... .... .. . x
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.
INDEMITY: 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� DA'� tractor
1/1 or Agent