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PERMIT REQUEST FORM
Date of Reouest: 08/11/16
Job number: 887032982
Job address: 8625 MAPLE LN� City: EDMONDS Zip: 98026
Project mgr: Sharon Davenport PM contact #: (425) 429-4270
PM email: sharon.davenport@pse,com
Estimated job start date;
Estimated job completion date: 09/23/16
Description of work to be performed:
JE c�...to irive tiga.te-and -re.pajr.. e 4aa.s"n-alapro; . fAR_ BC- E..AD:Dl E;,S.C,..A. 3,X5L—
CUT IS TO BE
__ _ IN CONCRETE. ONE WEST BOUND LANE TO BE CLOSED. CUT IS
_NEAR-NORTHWSIDE OF STREET NEAR CURB IN ROW,
Pavement cut? 0Yes
No
If yes, Dimensions of Cut:
Length 3' Width5 _m_ __........... ...._
How many cuts? 1
Surface Type CONCRETE
Lane closed
Require trenching? LiYes
[DNo
If yes, Dimensions of trench;
Length Width Depth
Method of installation:
Traffic impact:
Road closed
Dyes
No
Lane closed
Eyes
ONO
How Many? I Direction? West
Shoulder closed �l'es
Z No
dYes
Sidewalk closeEl
LKJ
No
Emergency Contact: MIKE BLOOD
Cell Number: (425) 864-6154
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AUG 15 2016
i E -V L0P[V, -N-F St f 1VJ(} S
ROW PERMIT NO.: ENG L ce — 3 >
ISSUE DATE:
.tG ' T -10F -.WA R NS , � CTION - PERMIT APPLICATION
PROJECT NAME: 887032982
CONTRACTOR: PSE/Infrasource
Mailing Address: 1660 Park Lane. Burlington, WA 98233
_......_ ----,,,,,,,,,,,m
State License # INFRASL871 C2
_.� ._..... __ . ..... .......... _.............. ..
City Business License #: NR -019840
CONTACT: Sue Sidick
Phone #: 425-457-6353
Fax #: - -
rm;�il #: Susan.Sidick@pse.com
.Liahilit5 Insurance � ] Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 8625 Maple Lane
ROW WORK ASSOCIATED WITH T1 -1E FOLLOWING TYPE OF PROJECT:
0—Commercial
_ Commercial Subdivision 0 --'City 0--'CityProject Traffic Control 0........_.
❑ Multi -Family ❑M Single Family ❑ Other
❑ EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? ❑ Yes ® No
www..... _ .. PERMITS? �W NC��t.
ANY ASSOCIATL'i TS? F
D TS? � BLD# � m e..
DESCRIPTION OF PROPOSED WORK (Be Specific) : Permission requested to investigate and repair
leak on main at approx 400' E c/I of 88th AVE W & 13' n c/I of Maple Lane
1 3x5 cut anticipated in gravel. One west bound lane to be closed cut is near north side of the street near
curb in row.
I LAYFD WITHIN THF, LAST FIVE (5) YEARS YE
IT Ycar 887;
.... �....... + S NO
WAS SIRI I 1 O„VERI .,
PAVEMENT CUT: ® Yes No If yes, indicate size of cut: 3x 5
CONCRETE CUT: ❑ Yes 1-1 No If yes, indicate size of cut:w x„_,
RIGHT-OF-WAY II AREA I TOTAL DURATION
Sidewalk 48 Hi -s LF X LFI SF
Alley 72 Hr s +.nr.... LF X LF SF
Pai-king 72 firs + LF X LF SF
APPLICANT TO READ AND SIGN
ev �!s1�M01. YmYY �m �7 �NNJN14FI0%14WW- GmWdam"6eWrvwvYm' .�„�m�R" .'..f YYYmTtltrWY'i1 A" X ,M.MXfi ..........w..:"»x"s�' v pm.G.ardV cw'G41JnV'IY:.aw.� rvry OfgA�'v. Niu '. .P �sYwlnMlnmNM NiM1�YJm NNYOIwWw'.
*Traffic control and public safety shall be in accordance with City regulations as required by the City
Engineer. Every tlagger 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 worlcday — 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.
SIGNATURES ya �� (.,t��aeaor o,,��- -- DATE 08/15/2016
r Agent -
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE