BLD20160426.pdfRwarm CEMIFED
OCI' 10 2016 ROW PERMIT NO.: ENG
UE'VE1-0R0ENT SEFIVICES -C2 —6 L
ISSUE DATE:
RIGHT-OF-WAY CONSTRUCTION
PERM IT APPLICATION
PROJECT NAME: 107052771
CONTRACTOR: PSE/Infrasource
. ........ ...
Mailing Address: 1660 Park Lane, Burlington, VVA 98233
State "'Ce"sefi: INFRASL871C2
City business License #: NR -019840
CONTACT: Sue Sidick
P110" 4: 425-457-6353
Fax 4:
Susan,Sidick@pse.com
------- . ....
Liability Insurance [:] Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 524 Maple St
ROW WORK ASSOCIATED WITH TIIE FOLLOWING TYPE OF-- P.Romqn—
m -CO-1*1111-dEl
1 -0 -1 -al sul)(livision City Project ❑ Traffic Control (0111y)
F, Multi -Family [Z SingleFamily 0 OtljC-
L] EUC (PUD, VERIZON, PSE,
(A)MCAs'r, ovwsm:
is this permit part aha blanket permit? ❑ Yes No
El, DW
Work area is approx 26' N c/1 of Maple St
DESCRIPTION OF PROPOSED WORK (Be Specific):
& 186-421'W c/1 of 6th AVE S. 1 3x5 paving CLIt anticipated.
ly — .— . ......... ------ m . .....
W�IjQfiNTRE. LX�4yj
YEARS? YES[] NO ❑ Year: 1070
PAVEMENTCUT: Yes No If yes, indicate size of cut: 3 x5
CONCRETE CUT': ❑ Yes No If yes, indicate size of Nit:
RIGHT-OF-WAY DURATION
CLOSURE AREA TOTAL (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.
Ogitary sgiw.0 tr) S:an SAi;k
SIGNATURE Susan Sidick pso5 o-0,� s s 5' '°� 10/10/2016
DATE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
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