Echelbarger ROW permit.pdfr
I2CI PERMIT T l�C➢o : t±,1�dG ��� a� �
ISSUE DATE:
Kam
PROJE CST NAME: �� � 1 ��� � �.��� x ���,� � a..10 , i- CONTACT:
T:
CONTRACTOR: 204�_
Mailing address ; ... °:w oo Fax #s
State License #s � C jc'Aa '3't .sw
City Business License #s
Email #
L,aability tusuranne:e Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION:
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
i
[l Multi -Family
Subdivision
Single I+amily
COMC A.S ffi`, SD):
Ts this pee -reit part of a blanket permit?
( ] Yes No Job Number
Traffic Control (Only)
S"S(JCI1� I I's]� PERMITS? t3I,i��# '20 1 ENG
WAS STRE ET OVF LYE DITHIN T + LAST FIVE S YjJ , S? YES j_J NO Ll Year:
e C
PA.V:EMI+<i" T GUT: Yes -1 No If yes, indicate size of cut. r �x IU
C ONC + TE C;UT: El Yes 0 No If yes, indicate sire of cents
APPLICANT TO RE AD 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
lierifying completion of the required training in their possession. 4 '
*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 —ILIO EXCEPTIONS.
INDEMITY,. -flh Applicant has s
�App _ _ f Edmonds
harmless from injuries, darnaaes or claims of any 1c - eK, foreseen or unforeseen
jRd or descr loll atso
jptL_ _MLL _gy—
Lhat ma�bq_mgde agq:i List the CftyEf Edmonds qiAO oCitsdep AtijetiLq or qm oyeesLtn ludi defense
_ L
costs andLatt g-thi"gi
�mit.
I have read the above statements and understand the permit requirements and acknowledge that I must
follow all requirements ih order for the permit to be valid.
SIGNATURE
DATE
Conti -actor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE