ENG20170506-APPLICATION.pdfOE ED11,0 41
/A/c . I S90
PROJECT NAME: 106331772
CONTRACTOR: PSE/Infrasource
Mailing Address: 1660 Park Lane, Burlington, WA 98233
State License #: INFRASL871C2
City Business License #: N R-023614
iI I t ily-11110
CONTACT: Sue Sidick
Phone #: 425-457-6353
Fax #:
Email ": Susan.Sidick@pse.com
F-1 Liability Insurance Ej Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 19205 Olympic View Dr
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F Commercial El Subdivision F1 City Project El Traffic Control (Only)
F1 Multi -Family FX1 Single Family F-1 Other
F] EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? ❑ Yes No
I ANY ASSOCIATED PERMITS? BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific): Work area is approx 419'S c/1 of Cherry st
& 10' E -13' E c/l of Olympic View Dr to install gas service 1 3x5 paving cut 1 2x4 paving cut
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES El NO 0 Year: 1062i
PAVEMENT CUT: NJ Yes F-1 No If yes, indicate size of cut: 3 x 5
CONCRETE CUT: F-1 Yes F No If yes, indicate size of cut: _x_
RIGHT-OF-WAY DURATION
CLOSURE AREA TOTAL (NUMBER OF MONTHS)
Sidewalk 48 Hrs + LF X LF SF
Alley 72 Hrs + LF X LF SF
Parking 72 Hrs + LF X LF E
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 Sidick5 es-5.s `°� DATE 11/28/2017
Dale: 2016 09 30 OTST�O -0TW
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Job #:
106331772
Date:
11/7/17
Jurisdiction:
Edmonds
Right of Way Permit?
R] YES F] N;
Est. Start Date:
12/11/17
Est. Duration:
8 Hours
IQjU;1I1,k1 W a CLO I Lai 0, 1 Z4;01:101:4
Address: 19205 OLYMPIC VIEW OR
City / Zip: EDMON05 98020
Customer: Dan Crabtree 206-227-6094
PM / Insp: Kictra Hays
PHONE NUMBER
WORK DESCRIPTION:
INSTALL 15'OF 1-118"PE SCA T STUS AND 40'OF 1-118" PE SCA T EXT SET,4425 MSA
0/)Q AT 6 IN WC
PLAT MAP: 161 067
0= Fire Hydrant (122'N OF TIE IN
NO
• U411,MRAU RIVA
---------- I
'N S of CL A W of CIL
Construction Method
Open Trench E]
Trenchless 21
r]
❑
FLAGGERS #
OFFICERS #
MPH
SPEED LIMIT
❑
❑
TROLLY LINES
TRAFFIC SIGNAL
F-1 BUS STOP #
❑ ARTERIAL
❑ METER HOODS #
❑ NO PARKS #
*
commercial
n
Altered commercial
n
Leak Repair
Service Information
El Template Bar
*
Residential
E]
Altered Residential
n
CP Work
Diameter Meter
EFV
❑ Bollards 2.5" #
*
Multi -Family
❑
Replacement Service
n
Pothole
❑ 5/8" ❑ 250
❑
1800 ❑
Bollards 4" #
❑
New Constr.❑
Main Maintenance
Extension
11/8" 425
2600
❑
Stub
❑
service maintenance
❑ 11/4" ❑ 630
❑
10,000 n FUEL LINE PERMIT NEEDED
❑
Extension
❑
valve maintenance
F] 2" ❑ 1000
Fuel Line Length:
Compete Sery
F-1
Cut & Cap
Mtr Loc: OIR
Fuel Line Diameter:
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