ENG20170080-Application.pdfof Et)klo'
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ROW PERMIT NO.: ENG
ISSUE DATE:
PROJECT NAME: 892044640
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 #: Susan.Sidick@pse.com
n Liability Insurance E] Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 21608 81 st Ave W
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F Commercial F] Subdivision E] City Project [:1 Traffic Control (Only)
F] Multi -Family Z Single Family n Other
F] EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? El Yes W No
I ANY ASSOCIATED PERMITS? BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific) : Work area is approx 100' S C/l of 216th ST SW &
12'W c/1 of 81 st AVE W I 5x5 paving cut anticipated
To investigate and repair leak
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YESE] NOE] Year: 892b
PAVEMENT CUT: X1 Yes F-1 No If yes, indicate size of cut: -5 x 5
CONCRETE CUT: F1 Yes F1 No If yes, indicate size of cut: x
RIGHT-OF-WAY DURATION
CLOSURE AREA TOJ(NU1
BER OF MONTHS)
Sidewalk 48 Hrs + LF X LF Alley 72 Hrs + LF X LF 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.
Susan Sidick �° tr�`°�
-,C=Us
3/2/2017
SIGNATURE ��:=, M.07Z7W-0�
DATE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Job #: NO 01869 q
Date: 01-2-8-16
Jurisdiction:
Right of Way Permit? N YES El No
Est. Start Date:
Est. Duration:
I WORK DESCRIPTION:
PLAT MAP:
/00 'NQof CL
'N S of CL
'N S of CL
❑ FLAGGERS #
❑ OFFICERS#
MPH
SPEED WIT
❑
Commercial
❑ Altered Commercial
❑
Residential
❑ Altered Residential
❑
Multi -Family
❑ Replacement Service
E]
New Constr.
E) Main Maintenance
El
Stub
[:] service maintenance
❑
Extension
F] valve maintenance
❑
Compete Sery
[] Cut & Cap
PRE -INSPECTION REPORT
Address: 7 j(4()j? 21ST CVe
City/Zip: Fdmooc�s q90Z6_
Customer:
PM t Insp: CUST PHONE NUMBER
6
I.
2-1 6
_*j2*
'Eloo_�C�= -wt� ,
PHONE NUMBER
Construction Method
Open Trench [:]
Trenchiess F,,]
6 T S vV
Size of Cut I Surface Type
'E W of CL
'EWofCL—,------
Lj
TROLLY LINES
[j BUS STOP #
El METER HOODS #
r]
TRAFFIC SIGNAL
0 ARTERIAL
❑ NO PARKS #
0
Leak Repair
Service Information
❑ Template Bar
E]
('P Work
Diameter
Motor
EFV
❑ Bollards 2.5" #
[j
Pothole
[j5/8"
❑ 250
E)1800
❑
Extension
[:]11/8"
❑ 425
❑ 2600
F] Bollards 4"#
F] 11/4"
❑ 630
❑ 10,000
F] FUEL LINE PERMIT NEEDED
E] 2"
❑ 1000
Fuel Line Length:
Mtr Loc:
Fuel Line Diameter:
Date of Request: 03/01/17
Job number:
Job address;
Project mgr:
PM email:
892044640
21608 81 st Ave W City: Edmonds Zip: 98026
Veronica Paulson
veronica.paulson@pse.com
Estimated job start date:
Estimated job completion date:
Description of work to be performed:
04/05/17
04/05/17
Pavement cut? ®✓ Yes ®No
If yes, Dimensions of Cut: Length 5 Width 5
How many cuts? one
Surface Type asphalt
PM contact #: (253) 617-6023
Require trenching? Yes FNo
If yes, Dimensions of trench: Length Width
Method of installation:
Traffic impact:
Road closed Yes
No
Lane closed ✓Wes
FNo
Shoulder closed "Yes
No
Sidewalk closed FYes
FNo
Emergency Contact: Mike Blood
Cell plumber: (425) 864-6154
Depth
How Many? one Direction? south
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