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PROJECT NAME: 109098145
CONTRACTOR: PSE/Infrasource
Mailing Address: 1660 Park Lane, Burlington, WA 98233
State License #: INFRASL871C2
City Business License #: N R-019840
ROW PERMIT NO.: ENG
ISSUE DATE:
CONTACT: Sue Sidick
Phone #: 425-457-6353
Fax #:
Email l: Susan.Sidick@pse.com
F-1 Liability Insurance F] Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 212th ST SW & 76th Ave W
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F-1 Commercial 0 Subdivision n City Project Ej Traffic Control (Only)
F-1 Multi -Family X Single Family F] Other
F-1 EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? El Yes W No
� ANY ASSOCIATED PERMITS? BLD# ENG# I
DESCRIPTION OF PROPOSED WORK (Be Specific) : Relocate three sections of 6" STW IP Gas main and
one section of 2" PE gas main due to drainage conflicts with 212th ST SW 7 76th Ave W Intersection
improvement Project ( PIVI Bertrand Hauss) 4- 2x20 asphalt/ concrete cuts
� WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YESE] NOE] Year: 109el
PAVEMENT CUT: X1 Yes F-1 No If yes, indicate size of cut: -2 x20
CONCRETE CUT: F1 Yes F-1 No If yes, indicate size of cut: X_
RIGHT-OF-WAY DURATION
HLFX
TOTAL
CLOSURE (NUMBER OF MONTHS)
Sidewalk 48 Hrs +LF SFAlley 72 Hrs +LF SF
Parking 72 Hrs +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 W. � _ Ms=ST�'°� DATE 01/27/2017
201609300]:5130-01tl0' -
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE