ENG20170324-APPLICATION.pdfOV- EVA,10
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PROJECT NAME: 109106388
CONTRACTOR: PSE/Infrasource
Mailing Address: 1660 Park Lane, Burlington, WA 98233
State License #: INFRASL871C2
City Business License #: N R-023614
ISSUE DATE:
CONTACT: Sue Sidick
Phone #: 425-457-6353
Fax #:
Email #: Susan. Sidick@pse.com
❑ Liability Insurance El Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 16404 75th PL W
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F-1 Commercial 0 Subdivision El City Project F] Traffic Control (Only)
F1 Multi -Family X Single Family F] Other
R EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? ❑ Yes R* No
� ANY ASSOCIATED PERMITS? l3LD4 ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific): Work area is approx 689' S c/1 of
private dr and 12'W c/1 of 75th PL W to install gas service
1 3x5 dirt and paving cut anticipated.
� WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES E] NO 0 Year: 1096
PAVEMENT CUT: X1 Yes F-1 No If yes, indicate size of cut: - 3 x 5
CONCRETE CUT: F] Yes El No If yes, indicate size of cut: X_
RIGHT-OF-WAY DURATION
AREA TOTAL
CLOSURE (NUMBER OF MONTHS)
Sidewalk 48 Hrs + LF 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 °_.'_9= ° ��Psa� S=54eP°�
o.EMWNWO 5»0-0= DATE 8/10/2017
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
I'Llget SOUnd Enerpv Gas Pre-Insnect Form
Job #: 109106388
Date: 8/8/17
Address: 16404 76TH PIL W
Jurisdiction: Edmonds
City/Zip: Edmonds, 98026
ROW Permit: Yes
Customer: Shawn Pringle 425-286-7774
Est. Start Date: 11/13117
PM / Inspector: Jordan Cooper
Est. Duration: 1-112 Days
Job Description / Scope of Work
At 2" PE IP 2'W Edge Of Paving (902675)
C&C 518 Service (Prevous C&C in Property) Then
New Construction:
Install'! 1/8 Alt Residental PE SCAT Service 130' ( 12' Stub& 118' EXT) And Set A630 OL.
I rnnctrmirtinn Mathnrl
PLAT Map: 157.07
16404 75th PI SW
109106388
A6:
All Scat/ Trenchless
t
N
Private DR
Ln
EXISTING
Water
689'
S
of CL
Private Drive
Work Location
& 12, W of CL 75th PI W
Size of Cut
3x5
Surface Type
/A
of CL
&
of
CL
Service
Diameter:
of CL
Information
1-1/8" PE
&
Flaggers #:
of CL
Street Information
y Arterial:
N
Job Type
Altered Residential Svc
EFV:
1-1/8" - 2600 - 9999144
Police #:
N
TCP:
y
sou,vo
FNI f�U
Meter:
A630 I F--T
Speed Limit:
25
No Parks #:
y
Meter Loc:
02 - OFIL
Trolley Lines:
N
Mtr Hoods #:
N
Del Press:
6" W.C.
Traffic Signal:
N
Bus Stop:
N
Bollards:
2.5" # 4" #
ADA Ramps #:
N
Route #'s:
N
Date of Renuest- R/9/2(117
Job Number:
Job Address:
Project Manager;
PM Email
Esitmated Job Start Date:
109106388
16404 75TH PL W City: Edmonds Zip: 98026
Jordan Cooper PM Contact #:
Jordan.Cooper@pse.com
11/13/2017
Estimated Job Completion Date: 11/17/2017
Description of work to be performed:
At 2" PE IP 2'W Edge Of Paving (902675) C&C 5/8 Service (Prevous C&C in Property) Then Install 1 1/8 Alt Residental PE
SCAT Service 130' ( 12' Stub & 118' EXT) And Set A630 OL
Pavement Cut:
If yes, Dimensions of Cut:
How many cuts
Surface Type
❑✓ Yes F]No
1
soft/road
Trenching Required Yes F�No
If yes, Dimensions of Trench
Length 3' Width 5'
Length
Width
Method of installation: Hole Hog
Traffic impact:
Road Closed Yes No How Many Lanes 1
Lane Closed ✓ Yes No Direction: S
Shoulder Closed Yes No
Sidewalk Closed Yes No
Emergency Contact: Jordan Cooper
Cell Number: 425-6235302
Depth
Puget Sound Energy pv�
Traffic Centro
I IS � J -
Gregory Har,wod vV� Opp rf
Card No. 008997 Card Exp. 08113/2019 SOUND p ,�^
_} gregory.harwood@pse.com ASS i�I Pm' / 11 f�" A°�' (.•v �/
Job#109106388
q % 16404 75th PI W, Edmonds, WA
po August 91h, 2017
/ Sheet 1 of 1 brent.pogson@pse.com
(425) 462-3030
RESIDENT(S) WILL BE It
OF POSSIBLE TEI,
DRIVEWAY,
LEGEND
® 28'TRAFFIC CONE
® BORE PIT
TRAFFIC FLOW
TtFLAGGER
WORK VEMCLE
SIGN LOCATION
WARNINGFLAG
CHANNELIZATION
DEVICE SPACING
PER
TANGENT
40
80
N
30
60
20
40
igns and spacing to conform) to the MUTCD
dy of Edmonds standards.
2. All sidewalks, driveways, exits and egresses shall be
completely clear unless otherwise indicated.
3. Channelizing devices are 28" traffic cones.
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 75th PI W & approximately
689' SCL of 162nd St.
9. If used, place NO -PARK signs 72 hours in advance
of the day that the work is to be done.