ROW Permit - Edmonds.pdf
ROW PERMIT NO. : ENG___________
ISSUE DATE: ________________
RIGHT-OF-WAY CONSTRUCTION
PERMIT APPLICATION
PROJECT NAME: CONTACT:
SueSidick
107054345
CONTRACTOR:Phone #:
PSE/Infrasource
425-457-6353
Mailing Address: Fax #:
1660ParkLane,Burlington,WA98233
State License #: Email #:
Susan.Sidick@pse.com
INFRASL871C2
City Business License #: Liability Insurance Bonded
NR-023614
ADDRESS OR INTERSECTION OF CONSTRUCTION:
8010212thSTSW
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
Commercial Subdivision City Project Traffic Control (Only)
Multi-Family Single Family Other
EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Yes No
Is this permit part of a blanket permit?
H
ANY ASSOCIATED PERMITS?
BLD#____________ ENG#____________
DESCRIPTION OF PROPOSED WORK (Be Specific) :
Permission isrequestedFirstCuttotieintoexistion11/4peip
located21'Wc/lof80thAVEW.(Cutintoasphalt3x5)Toinstall2"maintoservicetheplatofBrackettsCorner
_________________________________________________________________________
SecondCut:tieintoexisting11/4pelocatedat21'Wc/lof80thAVEW&184'Nc/lof213thSTSW(CutintoAsphalt3x5)toinstall
2"MaintoservetheplatofBrackettsCorner.2-3x5pavingcutsanticipated
WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES NO Year:
107054345
35
PAVEMENT CUT: Yes NoIf yes, indicate size of cut: _________x_________
CONCRETE CUT: Yes NoIf yes, indicate size of cut: _________x_________
RIGHT-OF-WAYDURATION
AREATOTAL
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 anykind 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.
Susan Sidick
Digitally signed by Susan Sidick
6/26/2017
DN: cn=Susan Sidick, o=Puget Sound Energy, ou=Street Use
SIGNATURE DATE
Permitting, email=susan.sidick@pse.com, c=US
Date: 2016.09.30 07:57:30 -07'00'
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE