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Oct 3, 2.5
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Notes:
1. All signs and spacing
to the MUTCD and City of Edmonds
Traffic Control specs.
2. ChanneMM devices are 28'
iratfic cones.
3. All signs are 48' x 48' B/O unless
otherwise speciffed.
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4. Alert affected businesses.
Maintain two 11' lanes.
5.
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MAINTAIN TVVO
11' IANES
WORK AREA 3' WIDE TRENCH
Q 16' E OF C/L OF 76 AVE W
FROM 80' S TO 120' S OF C/L
OF 219th ST SW
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IPilchuck Contractors Inc SAP / Permit / Work Order Request
Foreman Name:
Address: /9c'9 7(c As--- ckJ
City:manc5.
Zip Code:
SAP#:
Leak#:
Plat:
Thomas Guide:
Locate #
No Parks Required?
Yes
Permit Required?
No
es
, City/Cnty?
Signal Light?
Yes
Flaggers Needed?
No
How many? %
Speed Limit 3 10
Job Start Notification?
No
Traffic Plan?
No
Floe?
No
2-Man?
Yes
Surface Tvpe: fb cickice
Hole Size:
Install:
Size/type/length-
Retire:
Size/type/length: S�TZ,3 /b
Check One
Service Leak Repair
STW Main Repair
Cl Main Repair
Bare Stl Repair
Valve Repair
Service Valve Repair (HOS)
Date: 9 � % /25
_Description / Diagram
of Work:
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One Call Instructions:
Lcc 4Q e c sF
solo. 76 A, �orn r
SO r 5
I Z:o' S 4�-- 2-19 34-
Circle One
CSTu-F,>Ext
Compl Main
Check One
Scattered Service Replacement Residential
Scattered Service Replacement Commercial
Cut & Cap
Short Main Rehabilitation Res (Few Feet)
Short Main Rehabilitation Com (Few Feet)
SAP# For Main Replacement (One Block)
Specific SAP# For Maintenance (Main or Service)
CP Work order
Wit•
(116,4070Ilitti):hsesoafisti�,7?p tiic%gcslf'IaUfifieiG�C i)
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-----------------
Page j :-D!
Tease include:
Complete dames of 2 cross str6ets
Location(s) or work
SAP Order #
2"PE'IP 670V
IcaA i
City of Edmonds Permit No: 0e '5 J > ?
RIGHT—OF—WAY CONSTRUCTION PERMIT. Issue Date: /— 0_6
A. Address or Vicinity of Construction: 7 11 L -
B. Type of Work (be sp c fic) � 1� ; + 0. ''o "'wei I_, me
C. Contractor:
Mailing Address:
State License cx 01 M A
Contact: �N �_q, �&i z kl
Phone:
Liability Insurance: Bond: $
D. Building Permit # (if applicable): Side Sewer Permit # (if applicable):
E. -f�' Commercial ❑ Subdivision ❑ City Project ❑ EUC (PUD, VERIZON, PSE, AT& T, OVWD)
❑ Multi -Family
INSPECTOR:
J ` " F. PAVEMENT CUT: EYES ❑ NO
CONCRETE CUT:. ❑ YES JRNO
❑ Other
f
G. SIZE OF CUT X
INDEMNITY. Applicant understands by his/her signature to this application he/she holds 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 but not.limite4 to the defense of any legal proceedings including defense. .
costs and attorney fees by reason of granting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERMLS 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..
♦ 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. All street -cut. trench work shall be patched with asphalt or City -
approved material prior to the end of the. workday - NO. EXCEPTIONS.
♦ Three sets of construction drawings of proposed work are required with the permit application.
CALL DIAL -A -DIG (1-800-424-5555) PRIOR TO BEGINNING. WORK
I HAVE READ THE ABOVE STATEMENTS AND UNDERSTAND THE PERMIT REQUIREMENTS AND ACKNOWLEDGE
THAT I MUST MAKE THE PINK COPY OF THE PERMIT A VAILABLE ON SITE AT ALL TIMES FOR INSPECTIONS
�t�1 �4 Date: Signature: �-`� . �_� (J.� ,ti. ,� 1� .�.� ,
-T-s (Contractor or Agent)
FOR CITY USE ONLY
Approved by:
Time Authorized: Void After �,r:n: /` l ..%r%(�' Disruption Fee/Fund 111:
Special Conditions:,o 'r ;rr, kC Ems::IAt _M 11,4� ee:
ll�T�tal Fee: 4
=' Xr 7T_ r V 4,44 ' ,--7_Receipt No:/,-
is rq r ;u �.i .� 1 f :� "I k r,>KL: of 1,3 V�r!r •Zk i Issued by:
\ Al Y K A w r1 T 1�, F r= r 1,C w ; t. �I 1 f� F " ► : " r .,' ! �' C : L . % nC `� PAC ' ;�
>�_ P. i i �� "►�i tA1 i!_l1 "T'\ t '�"�� .��+' ,:r � t`r`i k." i i �! i . l ti: f t� 'y �i'C 7 % r ?�l - �LL_ T�:'',r'� tt' i_-i`Gt?',
UPONCOMPLETION OF PERMITTED WORK, AN ENGINEERING FINAL
INSPECTION IS REQUIRED PER CHAPTER 18.00 OF THE EDMONDS
COMMUNITY DEVELOPMENT CO (Phone 4 5-771-0220, Ext. 1326)
FINAL APPROVAL OF PERMITTED WORK: DATE: 10 W.
nspector s T nature
For inspection requirements see Engin ring Inspection Information handout.
DAMy Documents%forms\Engnmg\ROWpermit_.doc