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ROW PERMIT NO.: ENGc- A'd
1 901 111304 11 W.11 w W 0 EX174 N BIL,
PROJECT NAME:64 CONTACT:
CONTRACTOR: 0 Pfione
Mailing Address: Fax #:
r(q
P0 Aax
State License it: M U0 F(124 1A Email #:
City Business License #: pp_ 0 tLA[Liabflity Insurance Eq—Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 112-- 11 1111 k
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
[I Commercial 0 Subdivision K City Project F-1 Traffic Control (Only)
n Multi -Family [] Single Family [:1 Other
F] EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? R Yes El No
ANY ASSOCIATED PERMITS? BLD# ENG#
WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES 0 NO Year:
PAVEMENT CUT: JZ Yes El No If yes, indicate size of cut: 3 x 06
_6
CONCRETE CUT: F] Yes n No If yes, indicate size of cut: x
RIGHT-OF-WAY
CLOSURE AREA
TOTAL
DURATION
(NUMBER OF MONTHS)
Sidewalk 48 Hrs + S� LF
X
ol-
5 LF
I Z s-4) SF
Alley 72 Hrs + LF
X
LF
SF
Parking 72 Hrs + LF
X
LF
SF
APPLICANT TO READ AND SIGN
*.Traffic. controt 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 requireme s n orde or the p rmit to be valid.
SIGNATURE114
DATE
_(/ntrac r or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE