ENG20170035-APPLICATION.pdfO� ED&104�
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PROJECT NAME: 109102418
CONTRACTOR: PSE/Infrasource
Mailing Address: 1660 Park Lane, Burlington, WA 98233
State License #: INFRASL871C2
City Business License #: N R-019840
CONTACT: Sue Sidick
Phone #: 425-457-6353
Fax #:
Email #: Susan.Sidick@pse.com
F-1 Liability Insurance [:] Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 926 Olympic Ave
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F-1 Commercial El Subdivision 0 City Project Ej Traffic Control (Only)
F1 Multi -Family nX Single Family F-1 Other
F] EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? ❑ Yes No
� ANY ASSOCIATED PERMITS? BLD# ENG#
DESCRIPTION OF PROPOSED WORK , (Be Specific): Work area is approx TN c/l of Olympic Ave
& 326'W c/l of Olympic Ave to install gas service 1 3x5 paving cut anticipated
I WAS STREET OVERLAYED WITHIN THE LAST FIVE, (5) YEARS? YES 0 NO 0 Year: 1096
PAVEMENT CUT: X1 Yes F-1 No If yes, indicate size of cut: 3 x 5
CONCRETE CUT: n Yes F1 No If yes, indicate size of cut: _X_
RIGHT-OF-WAY DURATION
AREA TOTSF
CLOSURE MBER OF MONTHS)
Sidewalk 48 Hrs + LF X LF
Alley 72 Hrs + LF X LF SF
Parking 72 Hrs + LF X LF SF
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.
SIGNATURE
Susan SIdICk .V'S=� , .�'US=S°�'°�
��,M6,WM0,.57�-0 . DATE 01/27/2017
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Job #:
Date:
Jurisdiction: Edmonds
Right of Way Permit? R] YES [] NO
Est. Start Date:
Est. Duration:
40 �00Nb � ",
Address:
926 Olympic Ave
City /Zip:
Edmonds 98020
Customer:
Chuck 206-459'0485
Upgrade to a 7-1-118 Scat Stub anda 20' 1-1/8 Scat Extension. Set a A630 meter at
6" WC
Open Trench E]
WORK DESCRIPTION:
Construction Method
Upgrade to a 7-1-118 Scat Stub anda 20' 1-1/8 Scat Extension. Set a A630 meter at
6" WC
Open Trench E]
PLAT MAP:
W
1-1/4 MPE IP 7'N -PL 9805619
Olympic Ave
SCATSTUB
SCAT EXTENSION
A630 IVISA 12b
926
Work Location
Size of Cut
§grface Type
Y111121
As halt
__p
F/I
FLAGGERS #
MPH F1 TROLLY LINES BUS STOP #
METER HOODS #
F
OFFICERS #
SPEED LIMIT TRAFFIC SIGNAL ARTERIAL
NO PARKS #
M
Commercial
Altered Commercial E] Leak Repair Service Information
Template Bar
Ej
Residential
Altered Residential Ej CP Work Diameter Meter EFV
F] Bollards 2.5" #
Multi -Family
Replacement Service E] Pothole 5/8" 0 250
1800 Bollards 4" #
New Constr.
Main Maintenance E] Extension 11/8" F� 425
2600
Stub El
service maintenance 11/4,- Fj, 6 3 0
10,000 FUEL LINE PERMIT NEEDED
Extension E]
valve maintenance 2" El 1000
Fuel Line Length:
compete sery E]
Cut & Cap Mtr Loc:
Fuel Line Diameter:
Notes:
1. All signs and spacing to conform to the MUTCD
and City of Edmonds standards.
2. All sidewalks, driveways, exits and egresses shall be
completely clear unless otherwise indicated.
3. Channelizing devices are 28" traffic cones.
4. Sign size can be a minimum of 48" x 48" and shall not
obstruct pedestrian access.
5. Crew is required to leave a minimum of 1 V for traveling
lane width.
6. Alert affected residents and businesses.
7. Work to take place between 9 a.m. and 4 p.m.
8. Work area will be 326" ECL of Olympic Ave & T SCL of
Olympic Ave.
9. If used, place NO -PARK signs 72 hours in advance
of the day that the work is to be done.
Olympic Ave
W20-1 X Y W20 -7A
PUGET
SOUND
ENERGY
Job#109102418
926 Olympic Ave Edmonds, WA
January 26th, 2017
Sheet 1 of 1 mitchell.peterson@pse.com
425-398-6071
LEGEND
28" TRAFFIC CONE
BORE PIT
TRAFFIC FLOW
NrFLAGGER
WORK VEHICLE
SIGN LOCATION
WARNING FLAG
926 RESIDENT(S) WILL BE INFORMED
OF POSSIBLE TEMPORARY
b n ? DRIVEWAY CLOSURE
CHANNELIZATION
DEVICE SPACING
MPH TAPER I TANGENT
55/70 40 80
35145 30 60
25/30 20 40
rn
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