ENG20170058-APPLICATION.pdfOf EDA,10
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ROW PERMIT NO.: ENG
ISSUE DATE:
it" i
MOO I
be -K-1,
PROJECT NAME: 106320765
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 4: Susan. Sid ick@pse.com
❑ Liability Insurance ❑ Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 22422 96th AVE W
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
❑ Commercial ❑ Subdivision ❑ City Project ❑ Traffic Control (Only)
❑ Multi -Family X❑ Single Family ❑ Other
❑ 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 192'S c/1 of 224th ST SW
& 20'W C/1 of 96th AVE W. 1 3x5 paving cut anticipated. to install gas service
� WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES ❑ NO ❑ Year: 1062i
PAVEMENT CUT: X1 Yes ❑ No If yes, indicate size of cut: 3 x 5
CONCRETE CUT: ❑ Yes ❑ No If yes, indicate size of cut: _x_
RIGHT-OF-WAY DURATION
AREA TOTAL
CLOSURE (NUMBER OF MONTHS)
Sidewalk 48 Hrs + LF X LF SF
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 PD°a Ps=SUee,°� a'a: 2016 OO.JO 0157 30 -0TOtl
Contractor or Agent
DATE 02/18/2017
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
WORK DESCRIPTION:
PRE1NSPECYQ�������
Job #:
106320765
'
Date:
2/6/17
Address:
2242296THAve VV
Jurisdiction:
Edmonds
City /Zip:
Edmonds98020
Right ofWay Permit?
P] YES [] NO
Customer:
Marie 206-200-4816
Est. Start Date:
PLAT
PM/|nop:
A B unsd425-495-4465
Est. Duration:
PHONE NUMBER
WORK DESCRIPTION:
Construction Method
Open Trench
PLAT
MAP:
W
1�
00
224th ST SW
F
40'SCAT 1-1/8"
T L
PE EXTENSION
A250 IVISA
PE STUB
22422
LID
00
Uj
Cn
Work Location
Size of Cut
Surface Type
asphalt parkiqq
FLAGGERS # 2
25 MPH
TROLLY LINES
BUS STOP #
[j METER HOODS #
OFFICERS #
SPEED LIMIT
TRAFFIC SIGNAL
E:1 ARTERIAL
E] NO PARKS #
Commercial
Altered Commercial
E] Leak Repair
Service Information
E] Template Bar
Residential F-1
Altered Residential
F] CP Work
Diameter Meter
EFV
[:] Bollards 2.5" #
F-1
Multi -Family 0
Replacement Service
E] Pothole
5/8" 250
1800 E] Bollards 4" #
New Constr. Ej
Main Maintenance
Extension
11/8" 425
2600
Stub El
service maintenance
11/4" F� 630
F]
10,000 [:] FUEL LINE PERMIT NEEDED
Extension El
valve maintenance
E] 2" 0 1000
Fuel Line Length:
IE1
compete sery E]
Cut & Cap
Mtr Loc: or
Fuel Line Diameter:
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