20160111112522.pdfPROJECT NAME:
ROW PERMIT NO.: ENG
ISSUE DATE:
RIGHT -OF -WAV CONSTRUCTION
PERMIT APPLICATION
CONTRACT01
y
"railing Address w
,.
State License # .
City Business License #:
ADDRESS OR INTERSECTION OF CONSTRUCTION:
CONTACT:
Phone #:
Fax #:
Email #:
Liability Insurance Bonded
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
Commercial
❑ Multi -Family
Subdivision
1 Single Family
❑ EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit?
City Project
❑ Other
❑ Yes ❑ No Job Number
ANY ASSOCIATED PERMITS? BLD# ENG#
Traffic Control (Only)
WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES El NO F1 Year:
PAVEMENT CUT
CONCRETE CUT:
❑ Yes In No
❑ Yes � No
If yes, indicate size of cut:
If yes, indicate size of cut:
x
x
RIGHT-OF-WAY DURATION
AREA TOTAL
CLOSURE(NUMBER OF MONTHS)
Sidewalk 48 Hrs + LF X LF SF
Alley 72Hrs + LF X LF SF
Parking 72 Hrs + LF IL 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.
MDEMITY: The Applicant has signed all application which states lie/she hold the City of Edrnonds
harmless frons illjUrics, darn or claims of any kind or descrilgion whatsoevcrjL)resen oi-LinfoiLeseen,
that inay be made against the City of Edinotids or any of its departinents, or ens ployees, including defense
costs and
I have read the above statements and understand the permit requirements and acknowledge that I must
follow all reqUil-elnCntS in order for the permit to be valid.
SIGNATURE DATE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE