ENG20160315.pdfo
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03 0 9 2016
ROW PERMIT NCS.: ENCC 01 ,&),-,2 f
ISSUE DATE:
7
RIGHT-OF-WAY CONSTRUCTION E
PERMIT APPLICATION AUG 0 9 2016
PROJECT NAME: 107052376 CONTACT: Sue Sidick
........ ..
CONTRACTOR: PSE/Infrasource 425-457-6353
Mailing Address: 1660 Park Lane, Burlington, WA 98233
. . . ... . .. . ..................... . . ........
State License #: INFRASI-871C2
City 131'silless "cense 9: NR -019840
Fax #:
Email #: SLisan,Sidick@pse.com
.. . ....................
❑ bility Insurance M
Bonded
ADDRESS OR INTERSECTION OF C'ONSTRUCTION: 22920 102 PL. W
.... . .....
ROW WORK ASSOCIATED wrrH T( -IE FOLLOWING ,rYPE OF PROJECT:
[:1 Commercial E-1 Subdivision City Project ❑ Traffic Control (0111y)
[:] Molti-Family 19 single Family 0 Other
El EUC (PtJD, VERIZON, PSE,
COMCAST, OVWSD):
Is [his permit part of a blanket permit? ❑ Yes No
ANY ASSOCIATED PERM-f'I'S? BL DI/I
DESCRIPTION OF PROPOSED WORK (Be Specific) : Permission requested to extend 2" gas main
for tie into plat at approx 660' s c/I of Edmonds Way & 11' W C/I of 102nd PL W.
I 3x5 cut anticipated in asphalt.
7
WAS STREETOVERLAYED WITHIN LAS' Fj�' N6 ❑0 Year: 107a
VEARS-? YES
PAVEIVIENTCUT: M Yes [] No Ifyes, indicate size of cut: 3-..-- x 5
CONCRETE, CUT: El Yes 0 No If yes, indicate size of cut: x
RIGHT-OF-WA _ DURATION
ARI+:A 'TOTAL
CLOSURE (NUMBER OF MONTHS)
Side-Nvalk 48 Hrs + LF X LIT SF
........
Alley 72 Hrs + LF X LF r ST
APPLICANT TO READ AM SIGN
*Traffic control and public safety shall be in accordance with City regulations as required by the City
Engineer. Every f�lagger 1111 -1st 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 EXCFP`I'IONS.
indemnity: The Applicant has signed an application which states helshe 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 rmist
follow all requirements in order for the permit to be valid.
SI(YNA'a`URE w,
DATE
C:ontraetor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE,
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