ENG20170184-APPLICATION.pdf0� Et)kjol
PROJECT NAME: 108597924
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 1l: Susan. Sid ick@pse.com
F1 Liability Insurance El Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 8609 244th ST SW
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F-1 Commercial El Subdivision [:1 City Project El Traffic Control (Only)
F-1 Multi -Family nX Single Family F-1 Other
F] EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? F-1 Yes No
� ANY ASSOCIATED PERMITS? BLD# ENG# I
DESCRIPTION OF PROPOSED WORK' (Be Specific) : Work area is approx 29' N c/1 of 244th ST SW
& 710' W c/1 of Hwy 99. To cut and cap gas service at main. 1 3x5 concrete cut anticipated.
� WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES [:1 NO 0 Year: 108EI
PAVEMENT CUT: R Yes R No If yes, indicate size of cut: - x
CONCRETE CUT: N Yes F] No If yes, indicate size of cut: 3 x 5
RIGHT-OF-WAY DURATION
AREA
E
CLOSURE MBER OF MONTHS)
Sidewalk 48 Hrs + LF X LF:STF
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 Sidickgw:° e°5=5v�1°� DATE 5/11/2017
W. 2016 09.30 01:5/]0 -0T00'
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
j,
PRE-INSPEC,104#
TION REPORT (03NBk,
Jl
JOB #:
108597924
5/5/V7
ADDRESS: 18,609 244011 St Sw
DATE:
JURISDICTION:
CITY/ZIP: Fdtnonds 98026�
ROW PERMIT:❑
T'HONE 4 3
CUSTOMER: Meityner Broflwrs (('Ontact N/hAwfle) (425) 212-2,4"90
_Fdnionds
YES ❑
NO
START DATE:
PM:
"lordan N1C[,tnm
P\9 PHOINK NUNIBM
425.,563-3 703
06/26/17
DURATION:
1 day
WORK DESCRIPTION:
INSTALL METHOD
Trenchless
Open Trench El
Neeelfltiggers
New Construct F_❑I
ExistiU_
PLAT�- 16 7 0L,,,',
........................ .......... ................ ....................
8609
NOTE:
ROW = 60' Wide
PAV = 35' Wide
"Hydrant H16-63 is
331' from tie-in
PA
i PYL
. ....................................................P,/
-L ..........................
Sidewalk
.... 2"_PE IP 29'N 920459 ---------------
EOP
............................ .........
............. ................................................
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...... ----------------------------------------------------------------------
12" STW I P 24'S
WORK LOCATION
Size of Cut Surface Type
270S of, C1,
244(h St, Sw
& '710 'E(j of CL 11%y!)!)
30 C'oncrete
'N S of CL
& 'E W of 0,
'N S of CL
& 'E W of C'L
❑ FLAGGERS # 2
35 MPH
❑
TROLLY LINES ❑ BUS STOP #
❑ METER HOODS #
❑ OFFICERS #
SPEED LIMIT
❑
TRAFFIC SIGNAL ARTERIAL
E] NO PARKS #
E] Commercial ❑
Altered Commercial
E]
Leak Repair Service Information
El Template Bar
Residential ❑
Altered Residential
D
CP Work Diameter Meter EFV Pressure ❑ Bollards 2.5" #
❑ Multi -Family ❑
Replacement Service
r
Pothole [2] 5/8" D 250 E] 1800E]
6" WC
El Bollards 4" #
❑ New Constr. F-1
Main Maintenance
El
Extension E]1-1/8" E] 425 ❑ 2600 E]
2#
F-1 Stub El
service maintenance
El 1-1/4" F] 630 ❑ 10,000 El
❑ FUEL LINE PERMIT NEEDED
F] Extension EE]
Valve Maintenance
2" ❑1000 ❑ 275
H
_?51#
Fuel Line Length:
E] Complete SVC
Cut & Cap I Mete, Lo.:
D3000
Fuel Line Diameter:
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