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ROW PERMIT NO.: ENG
ISSUE DATE:
PROJECT NAME: 106320014
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 #: Susan. Sidick@pse.com
F-1 Liability Insurance E] Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 711 Main St & 7th Ave N
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F] Commercial El Subdivision El City Project El Traffic Control (Only)
F] Multi -Family X Single Family R Other
F EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? F] Yes [*1 No
� ANY ASSOCIATED PERMITS9 BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific): Work area is approx 19'N c/l of Main St
& 230' E c/l of 7th AVE N to install gas service I 3x5 cut in paving anticipated.
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES El NO El Year: 106b
PAVEMENT CUT: Z Yes F-1 No If yes, indicate size of cut: -3 x 5.
CONCRETE CUT: F1 Yes F-1 No If yes, indicate size of cut: X_
RIGHT-OF-WAY
AREA TOTAL
CLOSURE
Sidewalk 48 Hrs + LF7x LF SF
Alley 72 Hrs + LF X LF I SF
Parking 72 Hrs + LF X LF r SF
DURATION
(NUMBER OF MONTHS)
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.
DgM1O"hg Nby 5�sa� U
SIGNATURE Susan SIdick P � _ a s-s°�`°� DATE 01/20/2017
Dale: 2016 0930 01:5730 -0T
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Job #: 106320014
Date: 1/13/17
Jurisdiction: EDMONDS
Right of Way Permit? E] YES ❑ NO
Est. Start Date:
Est. Duration:
PRE -INSPECTION REPORT
Address: 711 Main ST
City / Zip: Edmonds 98020
Customer: Lief 425-770-1970
PM / Insp: A. Baunsgard 4US-P 911M
PHONE NUMBER
WORK DESCRIPTION:
Construction Method
New Construct
50'..17.1/8,1Scat Extension. Seta meter
.Install
-42,5.
Existing
.. .......................... ............ ......... ........ ... ..
Open Trench F-1
Trenchless R1
PLAT MAP:
T
N
z
LU
A425 MSA
711
50' 1-1/8" PE
SCAT
EXTENSION
PE SCAT
STUB
2" PE -A IP 19'N CL 803078
Main ST
Work Location
Size of Cut
Surface Type
3x5
'N of CL __MAIN_S1_ of CL ______7_T_H_Ave_N_
Asphalt
'N S of CL
& 'E W of CL
'N S of CL
& 'EWofCL—
Rt
FLAGGERS # 2
25 MPH
❑ TROLLY LINES ❑ BUS STOP #
❑ METER HOODS #
R
OFFICERS #
SPEED LIMIT
❑ TRAFFIC SIGNAL E] ARTERIAL
❑ NO PARKS #
R
Commercial ❑
Altered Commercial
❑ Manifold Service Information
❑ Template Bar
0
Residential ❑
Altered Residential
❑ Main Extension Diameter Meter EFV
Pressure
F] Bollards 2.5" #
El
Multi -Family E]
Replacement Service
E Pothole ❑ 5/8" ❑ 250 ❑ 775
❑ 6"wc
❑ Bollards 4" #
[:]New
Constr. [j
Main Maintenance
E Bollards 11/8" ❑ 425 ❑ 1800
❑ 2#
P]
Stub R
service maintenance
❑ 11/4" ❑ 630 Q 2600
5#
F1 FUEL LINE PERMIT NEED
0
Extension ❑
Valve Maintenance
❑ 2" ❑ 1000 D 10,000
Fuel Line Length:
[]
Compete Sery D
Cut & Cap Mtr Loc: ❑ 4" E] IMO Ej NA
Fuel Line Diameter:
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