ENG20170078-Application.pdf-IAJ-
C. I. $90
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PROJECT NAME: 887033636
CONTRACTOR: PSE/Infrasource
Mailing Address: 1660 Park Lane, Burlington, WA 98233
State License #: INFRASL871C2
City Business License #: NR -019840
ROW PERMIT NO.: ENG
ISSUE DATE:
CONTACT: Sue Sidick
Phone #: 425-457-6353
Fax #:
Email #: Susan.Sidick@pse.com
F-1 Liability Insurance F-1 Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 857 Walnut ST
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F1 Commercial 0 Subdivision El City Project [:1 Traffic Control (Only)
Fj Multi -Family X Single Family F] Other
F] EUC (PUD, VERIZON, PSE,
CONICAST, OVWSD):
Is this permit part of a blanket permit? n Yes FAI No
� ANY ASSOCIATED PERMITS? I BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific): Work area isapprox35'NC/lofWalnut ST& 20'
W c/l of 9th AVE S 1 5x5 paving cut anticipated
To investigate and repair leak on gas mainline .
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YESE] NO [I Year: 887ei
PAVEMENT CUT: X1 Yes F-1 No If yes, indicate size of cut: 5 x 5
CONCRETE CUT: F-1 Yes F-1 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
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 -5tre�' nATF,
�. N,6.NM0,.5,,,0-0�. 3/2/2017
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
STREET USE PERMIT
Date of Request: 03/01/17
Job number:
Job address:
Project mgr:
PM email:
887033636
857 Walnut St
Veronica Paulson
veronica.paulson@pse.com
Estimated job start date:
Estimated job completion date:
04/05/17
04/05/17
Citv: Edmonds Zip: 98020
PM contact #: (253) 617-6023
Description of work to be performed:
Investigate & repair leak on gag mainline at approximately 2.5' NCI 181aln, it St & 20' \A/('I 9th
Ave S.
Pavement cut? lyes ®No
If yes, Dimensions of Cut: Length 5 Width 5
How many cuts? one
Surface Type asphalt
Require trenching? I I FNo
If yes, Dimensions of trench: Length Width Depth
Method of installation:
Traffic impact:
Road closed
Yes
®✓
No
Lane closed ✓
Yes
FNO
How Many? one Direction? south
Shoulder closed Yes
No
Sidewalk closedYes
No
Emergency Contact: Mike Blood
Cell Number: (425) 864-6154
Job #: NO
Date:
Jurisdiction:
Right of Way Permit? hg- YES ❑ NO
Est. Start Date:
Est. Duration:
Address: f'°? l,V., ( m V —C
City/Zip: CIM a ads 0
Customer:
PM / Insp: CUST PHONE NUMBER
PHONE NUMBER
WORK DESCRIPTION:
Construction Method
Open Trench ❑
Trenchiess
PLAT MAP:
f
N
Qj
\A
1
Work Location
Size of Cut 'I Surface Type
So .
of wk 1-nv
&
'E of
CL.
jo`
'N S of CL
I E W of
CL
'N S of CL
&
'E W of
CIL
FLAGGERS # y LS MPH
F-1
TROLLY LINES
❑ BUS STOP #
❑ METER HOODS #
❑
OFFICERS # SPEED LUT
n
TRAFFIC SIGNAL
❑ ARTERIAL
NO PARKS #
❑
Commercial ❑ Altered Commercial
D_q- Leak Repair
Service Information
El Template Bar
❑
Residential ❑ Altered Residential
F-1
CP Work
Diameter Meter
EFV ❑
Bollards 2.5" #
❑
Multi -Family Replacement Service
E]
Pothole
El
5/8" 2SO
R 1800 ❑
Bollards
F]
New Constr. F] Main Maintenance
E]
Extension
[j
11/8" ❑ 425
❑ 2600 4" #
E]
Stub n Service Maintenance
❑
11/4" ❑ 630
❑ 10,000 F-1 FUEL LINE PERMIT NEEDED
❑
Extension ❑ valve maintenance
❑
2" El 1000
Fuel Line Length:
❑
Compete Sery ❑ cut & cap
Mtr Loc:
Fuel Line Diameter:
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