ENG20170114-APPLICATION.pdfCit' ED&,o
4vc—s
. ]"oo
I I I
W11 H = I YIN N
PROJECT NAME: 109103726
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 #:
Email 4: Susan.Sidick@pse.com
n Liability Insurance [:1 Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 23819 & 23811 79th AVE W
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F] Commercial El Subdivision El City Project El Traffic Control (Only)
F1 Multi -Family FX_1 Single Family F-1 Other
F1 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 19' w c/L of
79TH ave w & 162' s c/L of 238TH st sw 2 3X5 PAVING CUTS ANTICIPATED. To install twin service and cut and cap
existing service at 23819 79 AVE W.
� WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YESE] NOE] Year: 109h I
PAVEMENT CUT: Z 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_
MSidewalk
AY DURATION
AREA TOTSF
MBER OF MONTHS)
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 Sdick P tN°_�w-o- a� ���5 -t U. DATE,
Oa•e, M16N 07—M-0 4/72017
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Job #:
r�
Date:
Jurisdiebon: nW n x nnn � nm
Right of Way Permit? YES NO
Est. Start Date:
Est. Duration:
i
MAP:
am
PRE -INSPECTION REPORT
'N S of CLFLAG_
Address:
____._....µ.t�iun._--�..:N:.::..:.!�v
...w�.�,
r 1 M Al
City /,Zip:
C�
Customer:
SPEED LUTaµ.,.....
( �F�B7PfY8erciai
I 4
PM I Insp'
- . �, �ww��
�� �r "
.�xwma
itered Residential
[jMulti-Family
.� � W1�1�1r�4P� IVUPiAFxEft
...,..,i
...<......... ..............._...,mx.
New Constr.
..... ConstructionMethod
_
k .r
;.
<
_�
[_.� Service Maintenance
Open Trench ❑
a
[j valve Maintenance
.l
Trenchiess Q
I ., o
__...
'N S of CLFLAG_
�
____._....µ.t�iun._--�..:N:.::..:.!�v
...w�.�,
�i..
mMrwG..4�ux,uinuuuvuunu,nwnrnwuunuuuum�nnummmmmmmrnrnnuuuuuuuuu�luuuuuuuum
C�
OF FICEf;S11
SPEED LUTaµ.,.....
( �F�B7PfY8erciai
I 4
Faltered (orrurrevrcial
TRA9 .ic 51GNAL. ] AEti'E{21AI....._._..._
esidential[
itered Residential
[jMulti-Family
Diameter
Replacement Service
(�
New Constr.
[. Main Maintenance
[ ]
Stub
_�
[_.� Service Maintenance
Extension
[j valve Maintenance
.l
Compete Sery
[Cut & C:ap
(111(, pud
❑ 11/4" [71 630
❑ 2" ❑ 1000
Mtr Loc:._-..
�..] METER L1C&{7E)S #
r] NO PARKS 4
Tenn plate. clap,.. _... .
NF1/..__-_....__....u...m �Y j.� x�� .�� ��x'W�x
❑ 1800 mm Ei llard`7.. #
re
2600 n Llcallards 4" #
_._.._.._.__
❑ 10,000 (] FUEL LINE PERM1F NEEDED
Friel Line Length:
FUel Line Diameter:
�
____._....µ.t�iun._--�..:N:.::..:.!�v
...w�.�,
ni":., W �."�f ,a�ig��._�____......_..._......................._........_,_,_,_,
pp¢_.........W.w.._r..
��f
m�..vm«�wmu'E i of PbM p,...�m.......m_..��...............y,.M.m.ry•«......«.
n w mmuuvunu�u
nn,a.i uawm,uwmx,xn y.,.n...xwr�moo-unmw
ROLLYmuLINES
[ wm]
TRA9 .ic 51GNAL. ] AEti'E{21AI....._._..._
Leak Repair Irif Monad :'tt
❑_
Diameter
[�
pothole ❑ /8"
x..�
( p
Extension_Z 11/8"
❑ 425
❑ 11/4" [71 630
❑ 2" ❑ 1000
Mtr Loc:._-..
�..] METER L1C&{7E)S #
r] NO PARKS 4
Tenn plate. clap,.. _... .
NF1/..__-_....__....u...m �Y j.� x�� .�� ��x'W�x
❑ 1800 mm Ei llard`7.. #
re
2600 n Llcallards 4" #
_._.._.._.__
❑ 10,000 (] FUEL LINE PERM1F NEEDED
Friel Line Length:
FUel Line Diameter: