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PROJECT NAME: 106321790
CONTRACTOR: PSE/Infrasource
Mailing Address: 1660 Park Lane, Burlington, WA 98233
State License #: INFRASL871C2
City Business License #: NR -023614
CONTACT: Sue Sidick
Phone #: 425-457-6353
Fax #:
Email1l: Susan.Sidick@pse.com
R Liability Insurance E:1 Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 23914 84th AVE W
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F] Commercial [I Subdivision F1 City Project E] Traffic Control (Only)
F] Multi -Family Z Single Family n Other
R EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? ❑ Yes No
� ANY ASSOCIATED PERMITS? BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific) : Work area is approx 175' N C/l of 240th ST SW
& 12'W c/l of 84th AVE W to install gas service 1 3x5 paving cut anticipated.
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES F1 NO El Year: 106b
PAVEMENT CUT: Z Yes ❑ No If yes, indicate size of cut: -3 x 5
CONCRETE CUT: F] Yes n No If yes, indicate size of cut: X_
RIGHT-7Hrs
DURATION
CLOAREA TOTAL (NUMBER OF MONTHS)
SidewaLF X LF SF
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 P �V= �g °_"� s°�`°� DATE 3/22/2017
�'x_W16 M07.5]3D -0TW'
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Job #: 206321790
Date: 3/6/17
Jurisdiction: Edmonds/ 5no CO.
Right ofWay Permit? [D YES [] NO
Est. Start Date:
Est. Duration:
PRE -INSPECTION REPORT * llth-JE),
Address: 23914 84th Ave W
City / Zip: Edmonds98026
Customer: Pick 425-299-8877
CUST PHONE NUMBER
PW1/|nop: ABou d425495 -446b
Construction Method
WORK DESCRIPTION:
Open Trench
InstaH 48'scat 1-1/8 stub and 135'Scat 1-118 Extension,
Set a 425 meter.
Trenchless
PLAT MAP:
W
Cn
23914
23912
U
00
wi
zo
135' scat extension 1-1/8" PE
A425 MSA
240th ST SW
Work Location
Size of Cut
Surface Type
IN S of CL
'EWofCL—
FLAGGERS # 2
25 MPH F1 TROLLY LINES
BUS STOP #
METER HOODS #
OFFICERS #
SPEED LIMIT n TRAFFIC SIGNAL
ARTERIAL
NO PARKS #
commercial
Altered Commercial F] Leak Repair
Service Information
E] Template Bar
E]
Residential F�
Altered Residential E) CP Work
Diameter Meter
EFV Bollards 2.5" #
E]
Multi -Family
Replacement Service E] Pothole
5/8" E] 250
E] 1800 Bollards 4" #
New Constr.
main Maintenance Extension
11/8" 425
2600
Stub
service maintenance
11/4" 630
10,000 [:] FUEL LINE PERMIT NEEDED
Extension
valve maintenance
E] 2" 1000
Fuel Line Length:
F-1
Compete Sery E]
Cut & Cap
Mtr Loc:
Fuel Line Diameter:
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' 23S14O4thAve W,Edmonds VV4
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March 1O.2O17
i Sheet of ryan.honoymeM@poo.uom
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Notes:
' 1.All signs and spacing toconform iothe MUTCD
|
and City o[Edmonds standards.
/ 2. All sidewalks, dhvowayo, exits and egresses shall be
|
completely clear unless otherwise indicated.
| 3. Channe|izing devices are 2O"traffic cones.
' 4� Sign size can boominimum o[48''x48"and mhoUnot
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| obebudpedestrian access.
' 5.Crew isrequired Uoleave ominimum of11'foxtraveling
|
lane width.
| 6 NedaO�o�d mo�an� and bueinooaea
O10 ' .
l|� 7. Work Vmtake p�onbetween Qa.m.and 4p.m.
'�" 8.Work area will bo18'ECLof84thAve VV&175'NCLnf
| 240th ST SW.
i 0. If used, p|ono NO -PARK signs 72 hours in advance
' " of the day that the work is to be done.
| LEaswo |
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RESIDENT(S) WILL BE INFORMED
OF POSSIBLE TEMPORARY
DRIVEWAY CLOSURE
23914 23912
240TH ST SW
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100'
6-0ZM
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28" TRAFFIC CONE
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PUGET
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TRAFFIC FLOW
FLAGGER
SOUND
SIGN LOCATION
m ENERGY
WARNING FLAG
Job#106321790
23914 84th Ave W, Edmonds WA
March 16, 2017
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Sheet 2 of 2 ryan.honeysett@pse.com
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Notes:
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1. All signs and spacing to conform to the MLITCD
o
and City of Edmonds standards.
F
10'10
2. All sidewalks, driveways, exits and egresses shall be
Q
completely clear unless otherwise indicated.
3. Channelizing devices are 28" traffic cones.
i
4. Sign size can be a minimum of 48" x 48" and shall not
obstruct pedestrian access.
5. Crew is required to leave a minimum of 11' for traveling
lane width.
6. Alert affected residents and businesses.
7. Work to take place between 9 a.m, and 4 p.m.
8. Work area will be 12' WCL of 84th Ave W & 175' NCL of
H3 AbM1"ai
o
a PARKING 240th ST SW.
aw�ava ®
9. If used, place NO -PARK signs 72 hours in advance
of the day that the work is to be done.
o a
ti
CD
N
100'
6-0ZM
LEGEND
28" TRAFFIC CONE
®
BORE PIT
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TRAFFIC FLOW
FLAGGER
WORK VEHICLE
SIGN LOCATION
WARNING FLAG
1;J4VkVi IN Nh' 210-111
Date of Request: 03/21/17
Job number:
Job address:
Project mgr:
PM email:
106321790 .
23914 84th Ave W City: Edmonds Zip. 98026
Andrew Baunsgard
andrew.baunsgard@pse.com
Estimated job start date:
Estimated job completion date:
Description of work to be performed:
-� �Prliir P 1
Ciit
04/03/17
04/07/17
Pavement cut? ®✓ Yes ®No
If yes, Dimensions of Cut: Length 3
How many cuts? 1
Surface Type pavement
Require trenching?Yes ®No
If yes, Dimensions of trench: Length 3
Method of installation: Hole hog
Traffic impact:
Road closed Yes
®✓ No
Lane closed
✓Wes
No
Shoulder closed FlYes
® No
Sidewalk closed
Yes
FNo
Emergency Contact: Andrew Baunsgard
Cell Number: (425) 495-4465
Width 5
PM contact #: (425) 495-4465
Width 5
Depth 36
How Many? alt Direction? North