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PROJECT NAME: 109101354
CONTRACTOR: PSE/Infrasource
Mailing Address: 1660 Park Lane, Burlington, WA 98233
State License #: INFRASL871C2
City Business License #: NR -019840
CONTACT: Sue Sidick
Phone #: 425-457-6353
Fax #:
Email 11: Susan. Sid ick@pse.com
F-1 Liability Insurance F-1 Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 10125236PLSW
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F-1 Commercial F] Subdivision El City Project E] Traffic Control (Only)
F1 Multi -Family Z Single Family M 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): Replace 3/4 stw" host @ 10125 & 3/4 STW'
twin @ 10133 with 1 1/8 pe host and twin ( long side ) at 163'W C/l of 101st PL W & 1T c/l of 236th PL SW
2 asphalt/ gravel 3x5 cuts anticipated
� WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES El NO F1 Year: 109b
PAVEMENT CUT: Yes ❑ No If yes, indicate size of cut: 3 x 5
CONCRETE CUT: ❑ Yes ❑ No If yes, indicate size of cut: X_
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.
D�gft�ly 62— by S.... SMkk
DPJ, � SW�, �P�,t SwM E ... gy, —Sb- U�
Susan (dick 7ffi"4=' 01/13/2017
SIGNATUREPDZ� 2016M W 07,Z.a'0dtdTgT' `US DATE
Contractor or Agent
Date of Request:
PERMIT REQUEST FORM
01/11/17
109101354
10125 236th PI SW
Gayle Plaisance
gayle.plaisance@pse.com
Estimated job start date:
Estimated job completion date:
03/27/17
Citv: Edmonds Zip: 98020
PIVI contact #: (253) 6176013
Description of work to be performed:
Rpnlare U4" STN81 hnqt nri 1 n 1 9.r) And .1/,A" qT\A/ t%A/in nni ni \A ' h 1 - 118LP
_E hnzt nnH t\um—
(long side) at 163'WCL of 101 st PI W and 17'SCL of 236th PI SW
Pavement cut? 0yes �No
If yes, Dimensions of Cut: Length 3 Width 5
How many Cuts? 2
Surface Type asphalt/gravel
Require trenching? E:]Yes ,/ No
If yes, Dimensions of trench: Length Width
Method of installation:
Traffic impact:
Road closed
ElYes
[E No
Lane closed
[Z]
Yes
No How Many? I
Shoulder closed
Eyes
11 No
Sidewalk closed
0
Yes
0 No
t-mergency (,
Coll Number
sm
Direction? South
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