ENG20170084-Application.pdfIA/C. ), $
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PROJECT NAME: 887033637
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
F-1 Liability Insurance F-1 Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 22325 76th AVE W
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
R Commercial El Subdivision E] City Project F1 Traffic Control (Only)
F-1 Multi -Family [M Single Family F-1 Other
Fj EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? El Yes W No
I ANY ASSOCIATED PERMITS? BLD# ENG# I
DESCRIPTION OF PROPOSED WORK (Be Specific): Work area is approx 81' N C/l of 224th ST SW
& 18'E C/l of 76th AVE W to investigate and repair leak 1 5x5 paving cut anticipated
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES 0 NO 0 Year: 887@j
PAVEMENT CUT: X Yes F-1 No If yes, indicate size of cut: -5 x 5
CONCRETE CUT: El Yes F-1 No If yes, indicate size of cut: X_
RIGHT-OF-WAY DURATION
CLOSURE AREA TOTAdSF (NUMBER 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 Sdick s°'°�
s
3/8/2017
pate: 2016.0330 01:5130 -0T00'
SIGNATURE
DATE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Job #:b 167 5 7
Date:
Jurisdiction:
Right of Way Permit? [N YES
Est. Start Date:
Est. Duration:
I WORK DESCRIPTION:
10W_V1"TT.W
I 7_4 f V' ST SL,/
ffim
PRE -INSPECTION REPORT
Address: 7-)L32_6 7614� cva w
City/Zip: FC66,4cc
Customer:
PM / Insp: CUST PHONE NUMBER
PHONE NUMBER
Construction Method
Open Trench n
Trenchless (D
N
rs
z
Size of Cut I Surface Type
& tX_ ('g)W of CL 7
'N S of CL
'EWofCL ---
'N S of CL
'EWofCL----
yj
FLAGGERS #A.
:3 0 MPH
0
TROLLY LINES n Bus STOP #
E] METER HOODS #
[:]
OFFICERS #
SPEED LIMIT
n
TRAFFIC SIGNAL 0 ARTERIAL
0 NO PARKS #
0
Commercial 0
Altered Commercial
Leak Repair Service Information
❑ Template Bar
[:]
Residential n
Altered Residential
CP Work Diameter Motor
EFV
❑ Bollards 2.5" #
0
Multi -Family ❑
Replacement Service
❑
Pothole 0 5/8" ❑ 250
0
1800 0 Bollards 4" #
❑
New constr. ❑
Main Maintenance
0
Extension F]11/8" ❑ 425
E]2600
❑
Stub ❑
service maintenance
0 11/4" ❑ 630
❑
10,000 [-]FUEL LINE PERMIT NEEDED
❑
Extension 0
Valve Maintenance
n 2" n 1000
Fuel Line Length:
❑
Compete Sery 0
Cut& Cap
Mtr Loc:
Fuel Line Diameter:
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Date of Request: 03/06/17
Job number:
Job address:
Project mgr:
PM email:
887033637
22325 76TH AVE W City: Edmonds Zip: 98026
Veronica Paulson
veronica.paulson@pse.com
Estimated job start date:
Estimated job completion date:
04/10/17
04/10/17
PM contact #: (253) 617-6023
Description of work to be performed:
Imipstsciate & repair leak on gas mainfine at approximately 81' NCI 224th St S\81 & 18' ECI
76th Ave W.
Pavement cut? FI/ Yes F]No
If yes, Dimensions of Cut: Length 5
How many cuts? one
Surface Type asphalt
Require trenching? es F,/]No
If yes, Dimensions of trench: Length_
Method of installation:
Traffic impact:
Road closed FYes
✓® No
Lane closed
Eyes
FNo
Shoulder closed Wes
F No
Sidewalk closed
Flyes
FNo
Emergency Contact: Mike Blood
Cell Number: (425) 864-6154
Width 5
Width
Depth
How Many? one Direction? East
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