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REC,EIVED
AUG 16 2016
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ROW PERMIT NO.: ENG3 01 (0 -.6 0 33 a
ISSUE DATE:
RIGHT-OF-WAY CONSTRUCTION
PERA41T APPL1CAr[, ION
PROJECT NAME: 01169k-,�
CONTRAcTOR:
Mailing Address:
............ .. ........ ..
State License #:
City Business License 9:
AUG 16 2016
CONTACT:
Phone #:
Fax 8:
....... ... ..
Email (AI-Mk46PO-0
El Liability Insurance El Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION:
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ROW WORK ASSOC' ED WITH THE FOLLOWING TYPE OF PROJECT:
❑ Commercial LZ Subdivision ❑ City Project Ll Traffic Control (Only)
❑ Multi -Family F-1 Single. Family ❑ Other
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Pli `E, U 0 j�u �E-RIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? El Yes [3 �No
DESCRIPTION OF PROPOSED WORK (Be Specific)- 1
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. .........
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FWAS STREET OVERLAYEDVVITIJIN THE LAST FIVE (5 YEARS? YES E] NO Year:
PAVEMENTCUT: 0 Yes Nq,, If yes, indicate size of cut: --X
CONCRETE CUT: El Yes D "N""o If yes, indicate size of cut: x
RIGHT-OF-WAY
AREA
CLOSURE
TOTAL
DURATION
(NUMBER OF MONTHS)
Sidewalk 48 Hrs + LF
X
LF
SF
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 a derstand the permit requirements and acknowledge that I must
follow all requird1tor t e ermit to be valid.
SIGNATURE DATE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
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