ENG20170075-Application.pdfov E01,10
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ISSUE D 4,TE:
PROJECT NAME: 106319716
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.Sidick@pse.com
❑ Liability Insurance ❑ Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 8711 200th ST SW
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
❑ Commercial ❑ Subdivision ❑ City Project ❑ Traffic Control (Only)
❑ Multi -Family ❑X Single Family ❑ Other
❑ EUC (PUD, VE RIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? ❑ Yes n* No
� ANY ASSOCIATED PERMITS? BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific) : Work area is approx 16'S c/l of 200th ST SW & 258'
E C/l of 88th AVE W also 15'N C/l of 200th ST SW & 258'W C/l of 88th AVE W to install gas service
1 3x5 paving cut anticipated and 1 2x4 asphalt/ soft surface cut anticipated.
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES ❑ NOE] Year: 10
PAVEMENT CUT: XJ 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 :VT
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_s-s"�'°5B DATE 3/1/2017
DaM 20W5A 0]:57:30 -0T00'
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
PRE -INSPECTION REPOR T
JOB #:
DATE:
JURISDICTION:
ROW PERMIT:
START DATE:
DURATION:
106319716
ADDRESS:
CITY/ZIP:
CUSTOMER:
PM:
2/17/17
Edinonds
YES Ej NO
03/27/17
I
15 days
40/b "J
8711 200th STS
Edmonds 98026
Robin Hartley
, I
C. M R
206-915-3885
,Jordan McLean
PNI PI NL NUMBER
425-563-3703
WORK DESCRIPTION:
INSTALL METHOD
TrencFless M—
Open Trench E]
From main, install apl,7ro.y. 90'(?f 1-1/8" PE seat svc., an(/ set an A250 meter.
Olcaytocittdi°ivell'tx)'(Isneeticd
New Construct 0
Existing
PLAT MAP: 162. 068
.............. ........................ - ............. ... .......... ...................................
................
N
8711
NOTE:
Stub* 33'
Ext: 50'
Power, CTV, Fiber,
all OH.
P?L
PVL
Curb/gutter, Asphalt
sidewalk on South
side.
ROW = 5Q' Wide
PAV = 21` Wide
................................................... P/L ........................
...............
....................................................................................................................................................
...................................................................................................................
STRM
....................... ................. ............................. ....... ...........................
�4-44,
4 ............ .........................
.............................................................. H2.0 .......
EDP
C/L
-
C/Lw.
..................................... .......................... .......................................................................... ....... .........
-f-------h
. ......... ...................
... ...... ..................
................................ STRM
WORK LOCATION
ECP
Size of Cut Surface Type
16 (Si)f CL ----20jb_SLSm— & 258 'E W of CL
88th live W
R5 Asphalt
15 CjSofCL &.-2,58— 'E W of CL
88th Ave W
2x4 Asphalt/Soft
'N S of CL & 'E W of CL
❑ FLAGGERS # 2 35 MPH F-1 TROLLY LINES
❑
BUS STOP #
❑ METER HOODS #
F-1 OFFICERS # SPEED LIMIT F-1 TRAFFIC SIGNAL
❑
ARTERIAL
❑ NO PARKS #
0 Commercial ❑ Altered Commercial R Leak Repair Service Information
F-1 Template Bar
F,/] Residential F-] Altered Residential n CP Work Diameter
Meter EFV
Pressure F-1 Bollards 2.5" #
F] MUlti-Family ❑ Replacement Service [-1 Pothole ❑ 5/8"
250 ❑ 1800
Fal 6" WC Bollards 4" #
❑
R New Constr. F� Main Maintenance E] Extension 1-1/8"
F-1425
2600
E]2#
F-1 Stub n service maintenance E] 1-1/4"
E]
630 El 10,000
0 25# ❑ FUEL LINE PERMIT NEEDED
❑ Extension R valve maintenance [:] 2"
El
1000 [] 775
Fuel Line Length:
F -/❑I compete Sery [-] Cut & Cap I Meter Loc: OR 08 1
Fuel Line Diameter:
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