109114329-887034981-76 ave w & 208th ST SW (2).pdfnF EVA,1(-),
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ROW PERMIT NO.: ENG
ISSUE DATE:
RIGHT-OF-WAY CONSTRUCTION
PERMIT APPLICATION
PROJECT NAME: 109114329/ 887034981
CONTRACTOR: PSE/Infrasource
Mailing Address: 1660 Park Lane, Burlington, WA 98233
State License #: INFRASL871 C2
City Business License #: NR-023614
CONTACT: Sue Sidick
Phone #: 425-457-6353
Fax #:
Email #: Susan.Sidick@pse.com
❑ Liability Insurance ❑ Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 76th AVE W & 208th ST SW
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
❑ Commercial ❑ Subdivision ❑ City Project ❑ Traffic Control (Only)
❑ Multi -Family ❑X Single Family ❑ Other
❑ EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit9
ANY ASSOCIATED PERMITS?
❑ Yes ® No
BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific) • Work area is approx 187' N C/I of 208th ST SW &
9' W c/I of 76th AVE W Also 258' N c/I of 208th ST SW & 9' W c/I of 76th AVE W (2) 4x6 paving cuts anticipated
also 887034981 work area was approx 158' S C/I of 208th ST SW & 9' W c/I of 76th AVE W.(1) 4x20 paving cut
work was completed under emergency gas leak repair follow. Road to be overlay permit is requested as rush to beat over lay.
WAS STREET OVERLAYED WITHIN THE LAST FIVE 5 YEARS? YES ❑ NO ❑ Year: 1091
PAVEMENT CUT: ❑ Yes ❑ No If yes, indicate size of cut: x
CONCRETE CUT: ❑ Yes ❑ No If yes, indicate size of cut: x
RIGHT-OF-WAY
CLOSURE
AREA
TOTAL
DURATION
(NUMBER OF MONTHS)
Sidewalk 48 Hrs + LF
X
LF
SF
Alley 72 Hrs + LF
X
LF
SF
Parking 72 Hrs + LF
X
LF
SF
APPLICANT TO READ AND 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 understand the permit requirements and acknowledge that I must
follow all requirements in order for the permit to be valid.
-1 1 - Digile signed ,d Suse ,1111 /��/LO
Susan
Id IcK DNtl'Susan Sidi[k,=di,nitlin DepaNnUS ou=Muniapal
SIGNATURE RD1b. nn= emn2114'0'73936 0700 �nm �-Ds DATE
Dena: 2018.0] 24 0�:39 38-0�'00'
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
October 17, 2017 EMERGENCY PRE -INSPECTION FORM
Address: �s�� l
Job #: �Cit zip:
p:
Date: 77— l�'j—L Customer:
Jurisdiction: CUSTOMER PHONE NUMBER
52 PM / Insp:
Work Description
Construction Method
Open Trench ❑
Trenchless ❑
_
KETCH
U�
a
b
c ®2
Work Location
Size of Cut
Surface Type
NSofCL_& 4 'E ofCL
V�
' S of CL C�6,0, & _K'EQbf CL
'NSofCL & 'EWofCL
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S 160068, Q 163070
07-13-2018
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Scale 1:559
Lat\Long=47.8109,-122.3353 O 4:01 PUGET SOUND ENERGY
PAVING
M
CHECK: CITY..
[j INSIDE [:1 OUTSIDE /;�o dilk7 6/
TICKET: 5067773
PERMIM
SHEEP l OF
REQUESTED BY.
E] POTELCO M INFRASOURCE n PSE
DRAW LOCATION OF CUT AND NUMBER IT ACCORDINGLY.
11
IN
1146i� tv
—' M
MATCH 4
FROM DRAWING
ABOVE
TYPE
TY ' r
(SEE KEY
;q
BELOW)
SIZE
(CALLED
OUT)
—
DEPTH
IN INCHES
LOCATION
SIZE
(ACTUAL
INSTALLED)
Example 1
A
2X8
6-
25'N CIL Test St
AA to complete
SAP ORDER NUMBER:
SAP NOTIFICATION NUMBER: -------
PM/PERSON RESPONSIBLE:
FORM FILLED OUT BY:
YES
NO
TRAFFIC CONTROL
[I
POLICE OFFICER
PLATE OVER HOLE
NO PARKS
El
SHALLOW UTILITIES "88 THAN'"
❑
IN RIGHT OF WAY
❑
PRIVATE PROPERTY
❑
UNDER TROLLEY LINES
❑
FINAL TICKET FOR THIS JOB
❑
EXTRAORDINARY NCC (OFFICE USE)
0
❑
LOCATE NUMBER:
DATE HOLE CLOSED:
DATE AA RECEIVED: —
AA LOCATE NUMBER:
KEY
C= CONCRETE IN STREET OR ALLEY (INGLUDING GUREI AND GurTERI
C/WC = CONCRETE WHEEL CHAIR RAMP
G/SW = CONCRETE SIDEWALK, DRIVEWAY APPROACH
(INCLUDING CURB AND GUTTER)
C/O = CONCRETE CURB OR GUTTER
A = ASPHALT
A/C = ASPHALT OVER CONCRETE
G/O = ASPHALT GRIND AND OVERLAY
V = VALVE (RAISE VALVE AND REPAVE)
B = BRICK (COBBLESTONE)
M = MISC (STRIPE, GRADING,E-rc.)
196702/14
October 17, 2017
EMERGENCY PRE -INSPECTION FORM
Job #:
Date:
Jurisdiction
E �W•
♦�
City / Zip:
Customer:
CUSTOMER PHONE NUMBER
PM / Insp:
oul1NF NI IMR
Work Description
Construction Method
kk
45ho
Open Trench ❑
Trenchless ❑
_
KETCH
a
b
02
Work Location
Size of Cut
Surface Type
/_ &'N S f CL C20 & W f CLLpy�U
'NSofCL & 'EWofCL
'NSofCL & 'EWofCL
PAVING
RtA5(-'
ADDRESS:
REQUESTED BY.
c1w.
r
GHEGK�
11 Ll POTELCO NFRASOURCE D PSF
tj IN�SIDE 7U�OUTSIDE
�E
DRAW LOCATION OF CUT AND NUMBER IT ACCORDINGLY'
00
MATCH 9
FROM DRAWING
ABOVE
jyp—E
(SEE KEY
BELOW)
---jjZE
(CALLED
OUT)
DEPTH
IN INCHES
LOCATION
SIZE
(ACTUAL
INSTALLED)
ExamP!e tA
2X8
all
26'N CIL Test St
AA to complete
SAP ORDER NUMBER: —2-K— �0-1
SAP NOTIFICATION NUMBER:
PM/PERSON RESPONSIBLE: -e—
FORM FILLED OUT BY:
TRAFFIC CONTROL
POLICE OFFICER
PLATE OVER HOLE
NO PARKS
SHALLOW UTILITIES "$$ THAN 18)
IN RIGHT OF WAY
PRIVATE PROPERTY
UNDER TROLLEY LINES
FINAL TICKET FOR THIS JOB
EXTRAORDINARY NCC (OFFICE USE)
1967 ON1 4
LOUAI L NUM01=1i;
DATE HOLE CLOSED:
DATE AA RECEIVED:
AA LOCATE NUMBER;
YES
z
NO
El
KEY
C =
CONCRETE IN STREET OR AILEYONCLUDING 6UR13 AND GUTTER)
El
29
C/WC =
CONCRETE WHEEL CHAIR RAMP
11
C/SW =
CONCRETE SIDEWALK, DRIVEWAY APPROACH
ONCLUDING CURB AND GUTTER)
11
C/o =
CONCRETE CURB OR GUTTER
13
A =
ASPHALT
79
A/C =
ASPHALT OVER CONCRETE
El
io
G/O =
ASPHALT GRIND AND OVERLAY
li
-0
V =
VALVE (RAISE VALVE AND REPAVE)
-�m
B =
BRICK V-13LE-DNE)
El
M =
MISC (STRIPE, GRADING, FTC.)
0
LO
TN
2" STW IP 15'S w
'S
ww
v �
20815
No electric grid information available
S 160068, Q 163070
06-25-2018
The informaflon on the olochadmopsis.rupbOecf tochange wllhooI notice. P.O.f Sound Enehj kehjj.h1 anlYyaipereg person
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DEACT 2'' STW 15'S 892853
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892853
7510-7520
Scale 1:51 1
Lat\Long=47.8102,-122.3352 O
Q PUGETSOUND ENERGY
Puget Sound Energy
Traffic Control Supervisor:
Stephen R Gadke
Card No. 010741
Exp.5/31 /2021
stephen.gadke@pse.com
(425)424-64�31p�� �p
,�y¢Qst�rLCx�_
LEGEND
®
28" TRAFFIC CONE
®
WORK PIT
TRAFFIC FLOW
WORK VEHICLE/
FLASHING LIGHTS
SIGN LOCATION
RIGHT OF WAY
Row
Row
CHANNELIZATION
DEVICE SPACING
MPH
TAPER
TANGENT
55/70
40
80
35/45
30
60
25/30
20
40
MM
OM
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4
PUGET
SOUND
ENERGY
JOB# 887034981
208th St SW & 76th Av W Lynnwood, WA
7/22/2018
stephen.gadke@pse.com
425-424-6431
Sheet 1 of 1
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COLLEGE PLACE
MIDDLE SCHOOL
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208TH ST SW
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Notes:
ROAD 7 1. All signs and spacing to conform to the
WORK N MUTCD and City of Lynnwood standards.
AHEAD 3: 2. All sidewalks, driveways, exits and egresses
shall be completely clear unless otherwise indicated.
3. Channelizing devices are 28" traffic cones.
Use traffic drums (barrels) with steady burning
Type C lights on all State State Routes and Hwys.
4. Sign size can be a minimum of 36" x 36" and
shall not obstruct pedestrian access.
5. Crew is required to leave a minimum of 11' for
traveling lane width.
6. Alert affected residents and businesses.
7. Work to take place between 9 a.m. and 4 p.m
unless otherwise specified. All work for arterials
and major roadways will be from 9 a.m. to 3 p.m.
8. Work area will be Work area will be 9' W CL of 76th
Av W & 148-168' (Approx.) SCL of 208th St SW.