23500 84TH AVE W23500 84TH AVE W
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C ty of Edmonds
RIGHT-OF-WAY CONSTRUCTION
PERMIT permit Number.
Issue Date:
A. Address or Vicinity of Construction: 23500 - 84 AV W (9722950 )
B. Type of Work (be specific): Relocate with 2"Plas tic Gas Main per
attached 8&W# 9722990 to conform w/ City atnrm r>rain Prn1Pet
C. Contractor: Puget Sound Energy Contact: Tom Ling / Daniel Chan
Mailing Address: 1122 75 St SW Everette Phone: (425) 356-7530
State License #: 98203 Liability Insurance: Bond: S
D. Building Permit # (if applicable):
Side Sewer Permit # (if applicable):
E. ❑ Commercial ❑ Subdivision ❑ 'City Project ® Utility (PUD, GTE, WNG, CABLE, WATER)
❑ Multi -Family ❑ Single Family ❑ Other
INSPECTOR: I INSPECTOR: t , t'LnAc �
F. Pavement or Concrete Cut: ❑ Yes ®No G. Size of Cut:\ t ' , H. arge _, -
APPLICANT TO READ AND SIG
INDEMNITY: Applicant understands and by his signature to this application, agrees to hold the.Citfof Edmonds harmless fi om warier, 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 or not limited to the defense of any legal proceedings including defense.T ts; d attorney fees by *1! sgq ofg� a jing this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL
INSPECTION AND ACCEPTANCE OF THE WORK. ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREET PATCH
IS COMPLETED BY CITY FORCES, AT WHICH TIME A DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT.
Construction drawing of proposed work required with permit application.
A 24 hour notice is required for inspection; Please call the Engineering Division, 771-0220.
Work and material is to be inspected during progress and at completion.
Restoration is to be in accordance with City Codes.
Street shall be kept clean at all times.
Traffic Control and Public Safety shall be in accordance with City regulations as required by the City Engineer.
All street cut ditches shall be patched with asphalt or City approved material prior to the end of the working day;
NO EXCEPTIONS. %
I have read the above statements and understand the permit requirements and the pink copy of the permit will be
available on site at all times for inspection purposes,,,)p
g /17
Signature: Date:
(C tract Agent)
/ t
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY: �,' �� � RIGHT OF WAY DEPOSIT
TIME AUTHORIZED: VOID AFTER Z Q DAYS
SPECIAL CONDITIONS:
1xi ��1es'
COMMENTS:
DATE:
DISRUPTION FEE/FUND 111:
RESTQRATION'FEE:'
PERMIT FEE:
TOTAL FEE:
RECEIPT FEE:
ISSUED BY:
f
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Eng. Div. 1994
FIELD INSPECTION NOTES
Comments
Diagram
CONTRACTOR CALLED FOR INSPECTION
Partial Work Inspection by P.W.:
Work Disapproved By:
FINAL APPROVAL BY:
(Fund 111 - Route copy to Street Dept.)
❑ YES
Date:
Date:
❑ NO
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MCA&
NO TES
1. NOTIFY ONE CALL 48 HOURS PRIOR TO DIGGING A7'
1-800-424-5555. A
2. NOTIFY TOM LING, PSI; PRO.IT%C7' ATANAGER AT (425) 356-7530
PRIOR TO ANY CHANGE,&
F EDMONDS INSPECTOR 24 HO URS PRIOR TO
3. NOTIFY CITY O
CONSTR UC'77ON AT (425) 771-0220.
4. CALL DON FEINE OF CITY OF EDMONDS AT (425) 771-0220 TO
VERIFY DEP7'II AND I OCAT ION OF PROPOSL;'D S7'ORMDRAIN
PRIOR TO TIE-IN.
5. # # ## # DENOTES EXISTING ACTIVE SERVICE.
O 6. RETIREAI,I_, IN1IC71VESTUBS.
No. DESCRIPTION DATE BY APP'D
REVISIONS
AS BUILT INFORMATION
FITTER OR CONTRACTOR:
COORDINATOR:
F
E
DATE COMPLETED:
PERCENT COMPLETED:
TEST _
INSTALLATION / RETIREMENT
SUMMARY
TYPE OF TEST:
PPESSURF:
L
D
DATE ON:
TIME ON:
I / R
MAIN SIZE
MATERIAL
TOTAL FOOTAGE
DATE OFF:
TIME OFF_
—
TYPE OF PIPE:
,4-
PII'E MANUFACTURER:
--
--
-
-
TESTED FM
L T(�
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OP rAAP:
PLAT MAP: /G6-p68
'
WORK AREA: S//
PROPOSED MAIN
FOOTAGE
EMERGENCY SEC. No.:
MAIN SIZE
MATERIAL
TOTAL FOOTAGE
DESIGN PRESSURE: Ma
DD
Z"
MPE
350
SYSTEM MAOP: PsIG
IG
E
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PERMITS:
-
G
N
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AT
,236-00 "' 9 All A/
DRAWN: PCH41,1
9'0S- &I7
JOB No.
CHECKED:
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DRAWING NO.
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NOTES
I. NOTIFY ONE CALL 48 HOURS PRIOR TO DIGGING A7' a
1-800-424-5555.
2. NOTIFY TOM LING, PSE PRO.IECT MANAGER AT 425 356-7530
PRIOR TO ANY CHANGES.
3. NOTIFY CITY OF EDMONDS INSPECTOR 24 HOURS PRIOR TO
CONSTR UC7'ION AT (425) 771-0220.
4. CALL DON FEINE OF CITY OF EDMONDS AT (425) 771-0220 TO
VERIFY DEPTH AND LOCATION OF PROPOSED STORM DRAIN
PRIOR 7O 7IE-IN.
5. DENOTES E'XIS77NG ACTIVE SERVICE.
6. RE71RE AU, INAc777VE STUBS_
No. DESCRIPTION DATE BY APP'D
REVISIONS
AS BUILT INFORMATION
FITTER OR CONTRACTOR:
COORDINATOR:
F
DATE COMPLETED:
PERCENT COMPLETED:
E
TEST
INSTALLATION / RETIREMENT
'SUMMARY
TYPE OF TEST:
PRESSURE:
L
DATE ON:
TIME ON:
I i R
MAIN SIZE
MATERIAL
TOTAL FOOTAGE
DATE OFF: i
TIME OFF: '
TYPE OF PIPE:
PIPE MANUFACTURER:
TESTED BY:
� 1 co
voy
iNiiu.r
IJ�a L�vo1TG�.•n
OP MAP:
PLAT MAP:
__ _
WORK AREA:
PROPOSED MAIN FOOTAGE
EMERGENCY SEC. No.:
MAIN SIZE
MATERIAL
'TOTAL FOOTAGE
DESIGN PRESSURE: PSIG
p
-7
MPE
3S0
SYSTEM MAOP: PSIG
PSIG
E
PERMITS: C/Tj� D� E�Iorl' j-S�
S
v
N
2 "'' - P 1IAN 1( GZXA7(�_
AT
23,5-00 94 AV Al
DRAWN:
6?'ZS-97
JOB No. 972Z /5'0
CHECKED:
E r7
DRAWINGNO.
9722950 / �/
APPROVED: %1Z�--
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