Shoreshire ROW permit- signed.pdfOf EDA.Ir-1.
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PROJECT NAME: R_7
CONTRACTOR:
Mailing Address: PO Lg 3 2-9
State License #: U1'J IVE-LC_(59P
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City Business License #: N R, b f 8 1 7 Q
ROW PERMIT NO.: ENG
ISSUE DATE:
CONTACT:
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Phone #: IL S % 5,4- . ,.,._-_3 24
Fax #:
Email #:
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,J:�JTiability Insurance onded
ADDRESS OR INTERSECTION OF CONSTRUCTION:
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
❑ Commercial 0 Subdivision ❑ City Project ❑ Traffic Control (Only)
❑ Multi -Family ❑ Single Family ❑ Other
❑ EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket pen -nit? ❑ Yes ❑ No
ANY ASSOCIATED PERMITS?
BLD# ENG#
DESCRIPTION OF PROPOSED WORD (Be Specific) : C�� STz_u GT P+'� Sn {
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WAS STREET OVER]LAYED WITHIN THE LAST FIVE (5) YEARS? YES ❑ NO-MYear:
PAVEMENT CUT: YesJ
❑ No If Yes, indicate size of cut; x Z.
CONCRETE CUT: Yes ❑ No If yes, indicate size of cut: x 3�
APPLICANT TO READ ANIS 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 un erstand the permit requirements and aelmowledge that I must
follow all requirement/n o der.fai the peri pit to be valid.
SIGNATURE Z' i ,- DATE 6
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Con -actor or Agent
NO WORD SMALL BEGIN PRIOR TO PERMIT ISSUANCE