Right of Way Application.pdfof EVAyr).
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ROW PERMIT NO.: ENG Xglft!�
ISSUE DATE:
OWNM : RM i--bU,(YV — (�
PROJECT NAME: Vl�' 1C1 �\ S`Ilv(`� �' 0.� CONTACT: Illi i & c�A� 1c.� n CX —
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CONTRACTOR:Phone #: 206
Mailing Address' p0 50 z2, 8pdi%1 Fax #:
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State License #. ,'I- Email #.
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City Business License #:,, � � Liability Insurance Bonded
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ROW ASSOCIATEDWITHTRE FOLLOWING
LLO G TYPEOF PROJECT.-
-Commercial
R' E T
Cmmercial Subdivision City
Project Lj Traffic Control (Only)
❑ Multi -Family ❑ Single Family
❑ EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit?
❑ Other
❑ Yes ❑ No
ANY ASSOCIATED PERMITS? BLD#
DIVISION
ENG#
T 1"'r1 On 5000-
DESCRIPTION
OF PROPOSED WORD (Be Specific) \ QA \1� tZ
WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES ]_] NO Ild Year:
PAVEMENT CUT: 0 Yes ❑ No If yes, indicate size of cut: x
CONCRETE CUT: ❑ Yes ❑ No If yes, indicate size of cut:
APPLICANT TO READ AND SIGN
*Trak 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 understand the permit requirements and acknowledge that I must
follow all requirements "n rd rfor the ex it to be valid.
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SIGNATURE _. DATE
i
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE