ENG20170108-Application.pdfJ OV EL)&1[_)'
M.1C. 1 $00
IVA N0,11MMIKIM WIN
PROJECT NAME: 887033649
CONTRACTOR: PSE/Infrasource
Mailing Address: 1660 Park Lane, Burlington, WA 98233
State License #: INFRASL871C2
City Business License #: NR -023614
ROW PERMIT NO.: ENG
ISSUE DATE:
CONTACT: Sue Sidick
Phone #: 425-457-6353
Fax #:
Email #: Susan. Sidick@pse.com
R Liability Insurance [:] Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 24001 Hwy 99
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F] Commercial 0 Subdivision El City Project E] Traffic Control (Only)
F Multi -Family 0 Single Family F] Other
F1 EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? F-1 Yes W No
I ANY ASSOCIATED PERMITS? BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific): Work area is approx 44'E C/1 of SR 99 &
170'S C/l of 240th ST SW with a 3x5 cut in sidewalk work area is out of SR 99. To investigate and reapir leak Under job #
887033649
I WAS STREET OVERLAYED WITHIN THE LAST FIVE, (5) YEARS? YESE] NOD Year: 8870i
PAVEMENT CUT: X Yes F-1 No If yes, indicate size of cut: -x
CONCRETE CUT: El Yes F-1 No If yes, indicate size of cut: 3 x 5
RIGHT-OF-WAY DURATION
CLOSURE AREA TOTqSF
(NUMBER OF MONTHS)
Sidewalk 48 Hrs + LF X LF
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 " =- ' � =US=5°�t°�
Date: 216- W 07:5]:]0 -0r00'
Contractor or Agent
DATE 3/30/2017
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Date of Request: 03129/17
Job number:
Job address:
Project mgr*
PM email:
887033649
24001 HWY 99 City: EDMONDS Zip: 98026
Sharon Davenport
sharon.davenport@pse.com
Estimated job start date:
Estimated job completion date:
Description of work to be performed:
PM contact #: -(425) 429-4270
C � �1' : % -. V g re T il g 0 FAI ki I I I I I v a ! 7111 rx a I I ZTAI wal o a g z I : ffe TAI a ff, as 4 1 a k WA I (*W. a -. to ITJ :
ADDRESS WITH WORK • BE DONE AT APX • OF SR 99 AND 170' SCL OF
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Pavement cut? Fv/-Iyes ®No
If yes, Dimensions of Cut: Length 5 Width 3
How many cuts? 1
Surface Type CONCRETE S[W
Require trenching? RYes R-/ No
If yes, Dimensions of trench: Length Width
Method of installation:
Traffic impact:
Road closed
Lane closed
Shoulder closed
Sidewalk closed
Elyes
RI/
No
OYes
Q
No
Dyes
R17 No
❑Yes
a
No
Emergency Contact: MIKE BLOOD
Cell Number., (425) 864-6154
Depth
How Many? Direction? West
t,o 0 t -A0
Job #: —10 3 3(D(49
Date: 11- Loy,
Jurisdiction:
Right of Way Permit? [21 YES ❑ NO
Est. Start Date:
Est. Duration: 7 � rka" c
F0MM2X*114TWz #991
Address: zt-kao I S, e-,'1' -
City / Zip:
Customer:
CL!y E NUMBER
PM / Insp: 6; 4 Z's �aPHONoq
PHONE NUMBER
WORK
DESCRIPTION:
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Construction Method
Open Trench E]
Trenchless
PLAT MAP: Lv't
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Size of Cut
Surface Typg
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�FGGERS #
MPH ❑ TROLLY LINES El Bus STOP #
El METER HOODS #
F]
OFFICERS #
SPEED LIMIT ❑ TRAFFIC SIGNAL 2ARTERIAL
❑ NO PARKS #
❑
commercial ❑
Altered Commercial Q'LeakRepair Service Information
F] Template Bar
F]
Residential E]
Altered Reqiclential❑CP Work Dianiolor Motor
EFV L] Bollards 2.5" #
Multi -Family F]
Replacement Service ❑ Potilole Lj 5/8" [-1 250
0 1800 Bollards 4" #
❑
❑
New Constr. E]
Main Maintenance ❑ Extension ❑ 11/811 F]425
❑ 2600
❑
Stub ❑
Service Maintenance
❑ 11/4" 630
10,000 [j FUEL LINE PERMIT NEEDED
❑
Extension ❑
valve maintenance
0 21, 0 1000
Fuel Line Length:
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Mtr Loc:
Fuel Line Diameter;
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