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22100 86TH AVE W
IPlichuck Contractors, In
Job#&? cog I Y5 NOT
DatigISLLI LQ5-
ihget I of 1. ca I SCTOALE
NAME 6 , k. L�4(J t-,,-7
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SPEED UMIT
1 .2
SIGN SPACING
MPH
x
45+
5W
35
350'
30
200'
25
100,
(I so- Seale)
CKANNWMON DEVICE SPACING
WH
1APER
TANGENT
50/70
40
80
35145
30
60
25/30
20
1 40
Notes:
1. All signs and spacing to conform
to MUTCD & City of r-
Traffic Control specs.
2. Channelizing devices are 28"
traffic cones.
3. All signs are 48" x 48" B/O unless
otherwise specified.'
4. Alert affected residents.
5. Work to take place between 9 a.m.
And 4 p.m.
6. Work area will be 1-50' of C/L of
2 2 2 -s4 & of C/L of
OWNERXONTR�,,(%'�' ESP
I OR IS RES ONSIBLE FOR
EROSION CONTROL AND DRAINAGE
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28' TRAFFIC CONE
WORK AREA
TRAFFIC FLOW
WCRK VEHCLE
SIGN LOCADON
[Pilchuck Contractors Inc SAP / Permit Work Order Request
c
te: /a 2 )5
Foreman Name: Da
Address: 2- 2-160 1�1'. A
city:
Zip Code:'
SAP#: 10(60-?S�6 — 9Y) Cos —/5/5
Leak#:
Plat: 16-5. 0K
Thomas Guide:
Locate #
No Parks Required? No. es)
P it Required? No
Cnty?
(19
Signal Light? Yes
Flaggers. Needed? Yes
How many?
Speed Limit a 5-
Job Start Notification?
Traffic Plan?
Hoe?
2-Man?
Surface Type:
Hole Size:
Install:
Sizeltyp4/length-
Retire:
Size/typellength:
I=
Kfgjw
M-
ELTMKMI
�Wm-
Check One
Service Leak Repair
STW Main Repair
Cl Main Repair
Bare Stl Repair
Valve Repair
Service Valve Repair (HOS)
Description] Dianram of Work:
-------------
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"X
One Call. Instructions:
2 2 2-
s4 _5c,
LOC C; f 8?'� 4
V cn,
11 Al a -F 2a2 -s4 -5-L--
K-t I IF 2 2-
Circle One
Stub Ext Compi
Main
Check One
Scattered Service Replacement Residential
Scattered Service Replacement Commercial
Cut & Cap
Short Main Rehabilitation Res (Few Feet)
Short Main Rehabilitation Com.(Few Feet)
SAP# For Main Replacement (One Block)
Specific SAP# For Maintenance (Main or Service)
L ---------- CP Work order
. 0010-
;/0:' 200'N
19BB
Ln
IPlease include:
N * Complete Names of 2 cross streets
* Location(s) or work
* SAP Order
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Clt�, of Edmonds Pern-dt C>
RIGHT-OF-WAY
.��ONSTRUCTION PERMIT-- Issue Date:
A. Address or Vicinity of Construction: C) OL I bo (V V� 0 \ UJ
ff 1�1 I il
�� A " n, a e-
):-To ky)b�\'O;A� 11-'Z"'
Mailing Address: V 3 �),50 S�G
State License
City Business License #:
D. Building Permit # (if applicable):
Phone: r42, C2 ' L4 19 —4c -31
Liability Insurance: Bond: $
V
Side Sewer Permit # (if applicable):
E. F� Commercial E] Subdivision E] City Project EUC (PUD, VERIZON, PSE, COMCAST, OVWSD)
F� Multi -Family Single Family f��Other.'
INSPECTOR: Md
F. PAVEMENT CUT: E?V'ES El NO G. SIZE OF CUT x
CONCRETE CUT: YES F� NO
G. E] Mail Approved Permit F] Call for Pickup
APPLICANT TO READ AND SIGN
INDEMNITY. Applicant understands by hislher signature to this application helshe holds 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 anyof
,Jts departments or employees, including but not limited to the defiqnse of any legal proceedings including defense
costs andattorneyfeei by reason ofgranting this permit. .. 60
THE CONTRACTOR IS RESPONSIBLE FOR WORKMAgT�IAN6'�Id -TERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL
INtPECTION A'ND ACCEPTANCE OF THE WORK. ESMIATE'D RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREET PATCH IS
COMPLETED BYCITYTORCES, AT WHICH TIMEA DEBITOR CREDIT WILL BEPROCESSED FORISSUANCE TO THEAPPLICANT.
4 Traffic control and public safety shall be in -accordance with City regulations as required by the City Engineer. Every
flagger must be trai ' ned 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 acclolrdance - with City codes. All street -cut trench work shall be patched with asphalt or City -
approved material prior to thi�'endof the workday — NO EXCEPTIONS.
* Three sets of construction drawiQi'of proposed work are required with the permit application.
CALL DIAL-A-DIG�(17800-424-5555) PRIOR TO BEGINNING WORK
I HA VEREAD THE ABOVE STATEMENTS AND UNDERSTAND THE PERMIT REQUIREMENTS AND ACKNOWLEDGE
THA T I MUST MAKE T'HE PINK COP Y OF THE PERMIT A VAILABLE ON SITE A T ALL TIMES FOR INSPECTIONS
Signature: Date: —0'%S
(Contri-cio—r or Agent)
Approved by:
Time Authoriz; . V
Special Conditions.�
Zf—
C4
Call 425-771-0220, Ext. 1326for a 24-hour voice -recorded inspection request line. -
FINAL APPROVAL OF PERMITTED WORK: DATE:b -3 -6G
lnspep'�r's Signature
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
CADocuments and ScuingsTurtisNy Documents\Fonns\Engnrng\ROWpemit_.doc Revised 10/01/03