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107053978 Permit Request Form.pdf
PERMITREQUESTFORM DateofRequest: 04/28/17 Job number: 107053978 98020 23920104thAveWEdmonds Job address: City: Zip: (425)424-6475 AprilJones Project mgr:PM contact #: ______________________ PM email: april.jones@pse.com Estimated job start date: 05/28/17 Estimated job completion date: Description of work to be performed: Permissionrequestedtotieintoexisting4"MPEIPlocated12'WC/Lof104thAveWand 246'NofC/Lof240thPlSW(cutintoasphalt6'x4')install2"maintoservetheplatof ApplegateDivIIperattacheddrawing. Yes No Pavement cut? 4 6'4' Ifyes,DimensionsofCut:Length Width 1 Howmanycuts? ASPHALT SurfaceType YesNo Require trenching? 4 Ifyes,Dimensionsof trench:LengthWidthDepth Holehog Method of installation: Traffic impact: Yes 4 No Road closed 1 YesNo 4 East Direction? HowMany? Lane closed No Yes Shoulder closed 4 No Yes Sidewalk closed 4 Emergency Contact: DeanLatimer Cell Number: (253)350-6687