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ROW PERMIT NO.: ENG
ISSUE DATE:
PROJECT NAME: 887033861
CONTRACTOR: PSE/Infrasource
Mailing Address: 1660 Park Lane, Burlington, WA 98233
State License #: INFRASL871132
City Business License #: N R-023614
CONTACT: Sue Sidick
Phone #: 425-457-6353
Fax #:
Email #: Susan.Sidick@pse.com
_�Liability Insurance [:1 Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 7609 212th ST SW
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F1 Commercial F-1 Subdivision Ll City Project [:1 Traffic Control (Only)
F-1 Multi -Family FXJ Single Family F-1 Other
F] EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? El Yes W No
I ANY ASSOCIATED PERMITS? BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific) : Work taking place at the intersection of
212th ST SW & 76th AVE W to provide traffic control to vacuum out a valve box at
15'w c/l of 212th ST SW & 20'W c/l of 76th AVE W no cuts will be made
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES 0 NO El Year: 8
PAVEMENT CUT: X1 Yes NJ No If yes, indicate size of cut:
CONCRETE CUT: R Yes F-1 No If yes, indicate size of cut:
04
RIGHT-OF-WAY DURATION
AREA TOTAL
CLOSURE (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.
SIGNATURE
Susan SIdICk5-s°�`°� DATE
oa 4/25/2017
n16.w.wo,5,-0rw.
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Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
PERMIT REQUEST FORM
Date of Request: 02/24./17
Job number: 887033861
Job address: Inter of 212th St SW & 76th Ave W City: Edmonds zip: 98026
Project mgr: Gayle Plaisance PM contact #: (253) 617-6013
PM email: gayle.plaisance@pse.com
Estimated job start date:
Estimated job completion date:
06/26/16
Description of work to be performed:
provide traffic control to vaci jum a it valve box at I .1i'\81CI 219th St SNAI & 20'\AICI 76th Ave
W no cuts to be made, see last years job #887032662 permit #ENG20160213
Pavement cut? "Yes ZNo
If yes, Dimensions of Cut: Length VVidth
How many cuts?
Surface Type
Require trenching? "Yes ZNo
If yes, Dimensions of trench: Length Width
Method of installation:
Traffic impact:
Road closed Wes
No
Lane closed
Dyes
No
Shoulder closed 1717yes
El No
Sidewalk closedYes
nNo
Emergency Contact:
Celt Number.'
Depth
How Many? see tcpDirection? South
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