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Job #:
Date:
Jurisdiction:
Right ofWay Permit?
Est. Start Date:
Est. Duration:
106315076
9/7/16
Edmonds
[�] ,ES [] NO
Address:
City /Zip:
Customer
PM/|nap
�
410 6TH Ave 5
Edmonds
Jayne
COST PHONE NUMBER
Andrew Bounsgard 425-495-4465
PHONE NUMBER
WORK DESCRIPTION:
Construction Method
New Construction
Install a 16' 1-1/8 stub and a 20' 1-1/8 extension. Set a 250 meter.
Existing
PLAT MAP:
410
A250 IVISA
20' 1-1/8" PE
Extension
Beck
Ln.
2" MPE 4'S CL
107012949-2003
Work Location
Size of Cu Surface Typ2
Asphal
FLAGGERS # 2
MPH
TROLLY LINES BUS STOP #
E] METER [1OODS #
OFFICERS'#
SPEED LIMIT Ll
TRAFFIC SIGNAL I -j ARTERIAL
L NO PARKS #
1,j
Commercial
Altered Commercial
Manifold Service Information
L-1 Template Bar . ...... . .........
FL]
Residential
Altered Residential
main Extension Diameter Meter
EFV
Ej Bollards 2.5" #
F]
Multi -Family
Replacement Service
Pothole F] 5/8" 250
775
New Constr.
main Maintenance
Bollards
1800
_]
Stub
Service maintenance
11/4" 630
2600 FUEL LINE PERmrT NEEDED
F
Extension
valve maintenance
L] 2" F] 1000
D
10,000 Fuel Line Length:
F1
compete Sery
Cut & Cap
Mtr Loc:
Fuel Line Diameter:
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RECEIVED
SEP 0 8 2016
ROW PFRIVUTNO.: ENG -0"3'---)' C.
ISSUE 1)A --- -.-1..--.-1 ..... . . . . ......
RIGHT—OF—WAV CONSTRUCTION
PERM tT APPLICATION
PROJECTNAIME: 106315076
CONTRACTOR: PSE/Infrasource
Alailing Address: 1660 Park 1 -ane, BUdirlotOrl, WA 98233
gtaieT.isen e#: INFRASL871C2
C'tv Business "'C"se #: NR -010840
CON'T'AGU: Sue Sidick
.............
PlIt"le 4: 425-457-6353
Fax H:
— . . . . ............... .....
Email 11: Susan. Sid ick@psexom
❑ Liability lit"mranec 0 Bonded
.......... . . . . . . .. . .........
ADDRESS OR INTERSECTION OF CONSTRUCT[ON: 410 6 AVE S
ROW WORK ASSOC TAI'VI) W114-11 TIE FOL LOWING '[WE 01" PROJECT':
Traffic Control (Only)
El 'Alt, mily (XI Sin0c family El Otlici-
0 ETJ(1. (PUD, VERIZON,
CONICAST, OVWSD):
Is this Pei rrin: Part ot'a blanket Permit? El Yes H No
11 Y FB I�D 4
DESCRIPTION OF PROPOSEA) WOWC01c Specific) : Permission requested to install new 1-1/8" PE
gas service at approximately 4's c/1 of Beck Lane & 50'W c/1 of 6th AVE S.. I 3x5 Paving cut anticipated
tiVAS81RtL�l-,'OVERI,A)'VI)W,ITI-IIN,rl-IEI,ASI'NIVE(5)YEAlZSN( ❑ yeal.: focb —
I'AVEMENT CUT: Xj Yes Fj No if yes, indicate size or cut: 3
CONCRETE CUT: E.] Yes El No If yes, indicate size ol'cut: x
R IG LI`C-OF-1VA V DURATION
AREA TOTAL
CLOSURE (NUMBER OF .MONTHS)
Sidemilk 48 Ilr;s f Ix x ( I.,h S.
Alley 72 Hrs + LF X --- C.,li ,^ S1+
Parking 72 Ilrg + LE X LI Sl+
A-l'.'.VL1C'ANT 'I'0 READ AND SIGN
*Traffic control and public safety shall be iuz accordance with City regulations m required by the City
Eiigineer. Every flag,ger must be trained as required by (WAC:) 296-1.55-305 and most have certiticatio n
verifying comhtetion of the required training in their possession.
*Restoi-wion is to be in accordance with City codes and Standards. All street -crit trench wodc shall be
patched kvith aspllalt or City approved mirteriid prior to the erid 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 bind or description
whatsoever, foreseen or unforeseen, that may be made against the City of Edmonds or
any of its departments or employees, including defense casts and attorney fees by reason
of granting this pertnit.
It have read the above statements turd understand the permit: requirements and acknowledge that I must
follow all requireiner.rts in order br the perruit to be -,,,olid.
SIGNATURE I)A'I' I+',
09/08/201 6
� I —
Contr-aetor, or Agent
NO \TORIC SHALL BEGIN PRIOR TO I'MART ISSUANCE