ENG20170079-Application.pdfOV EVA.10
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ROW PERMIT NO.: ENG
ISSUED.
PROJECT NAME: 887033706
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
F-1 Liability Insurance E] Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 17003 Talbot Rd
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F-1 Commercial 0 Subdivision F1 City Project El Traffic Control (Only)
F-1 Multi -Family Z Single Family F] Other
F-1 EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? El Yes FAI No
� ANY ASSOCIATED PERMITS? BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific) : Work area is approx 11' N C/l of 171 st ST SW &
9' E c/l of Talbot Rd 1 3x5 paving cut anticipated
To investigate and repair leak
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YESE] NOE] Year: 887@j 1
PAVEMENT CUT: N Yes F-1 No If yes, indicate size of cut: -3 x 5
CONCRETE CUT: El Yes R No If yes, indicate size of cut: X_
RIGHT-7Hrs
DURATION
AREA EJ
CLOS(NUMBER OF MONTHS)
SidewalLF X LFAlley 72 Hrs + LF X LFParking 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 �=� U�@�'�'=Us �`°� DATE
oa� �s��os,3o-0 3/2/2017
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
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Job XLQUL�
Date: I—ZG-17
Jurisdiction: F A M ml 6S
Right of Way Permit? N YES ❑ NO
Est. Start Date:
Est. Duration:
I
Address: 170(93 TA(-A(:9T 1Z
City/Zip: UntokldA qV026
Customer:
PM / Insp: CUST PHONE NUMBER
PHONE NUMBER
WORK DESCRIPTION:
Construction Method
Open Trench ❑
L—cc-Ac
Trenchless
PLAT MAP:
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W., —Or -
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171 6 1 S 1,/
Work Location
Size of Cut
I Surface Type
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FLAGGERSLflLj_ MPH
❑ TROLLY LINES ❑ BUS STOP #
❑ METER HOODS #
❑
OFFICERS # SPEED LIMIT
.
E] TRAFFIC SIGNAL [j ARTERIAL
NO PARKS It
❑
Commercial ❑ Altered Commercial
[.,,Leak Repair Service Information
El Template Bar
❑
Residential ❑ Altered Residential
E) CP Work Diameter Motor
EFV Bollards 2.5" #
❑
Multi -Family ❑ Replacement Service
L] Pothole 0 518" [:] 250
n 1800 ❑
Bollards 4" #
❑
New Constr. [21—Main Maintenance
Ej Extension E) lim, F]425
[j2600
Stub El Service maintenance
E] 11/4" 0 630
[j 10,000 E] FUEL LINE PERMIT NEEDED
Extension n valve maintenance
n 2" EJ 1000
Fuel Line Length:
E]
Compete Sery E] Cut & Cap
Mtr Loc:
Fuel Line Diameter:
0/> '14
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60,01,100
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Date of Request: 03/01/17
Job number:
Job address:
Project mgr:
PM email:
887033706
17003 Talbot Rd City: Edmonds Zip: 98026
Veronica Paulson
veronica.paulson@pse.com
Estimated job start date: 04/05/17
Estimated job completion date: 04/05/17
Description of work to be performed:
Tal bot R•
Pavement cut? FYes FNo
If yes, Dimensions of Cut: Length 3 Width 5
How many cuts? one
Surface Type asphalt
PM contact #: (253) 617-6023
Require trenching? Dyes r�]No
If yes, Dimensions of trench: Length Width
Method of installation:
Traffic impact:
Road closed Yes
No
Lane closed ✓Wes
FNo
Shoulder closed Wes
F No
Sidewalk closed ®Yes
No
Emergency Contact: Mike Blood
Cell Number (425) 864-6154
Depth
How Many? one Direction? West
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