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ROW PERMIT NO.: ENG
ISSUE DATE:
RIGHT-OF-WAY CONSTRUCTION
PERMIT APPLICATION
PROJECT NAME: 106341236
CONTRACTOR: PSE/Infrasource
Mailing Address: 1660 Park Lane, Burlington, WA 98233
State License #: INFRASL871 C2
City Business License #: N R-023614
CONTACT: Sue Sidick
Phone #: 425-457-6353
Fax #:
Email #: Susan.Sidick@pse.com
❑ Liability Insurance ❑ Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 21522 92 AVE W
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
❑ Commercial ❑ Subdivision ❑ City Project ❑ Traffic Control (Only)
❑ Multi -Family ❑iC Single Family ❑ Other
❑ EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit?
ANY ASSOCIATED PERMITS?
❑ Yes ® No
BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific) : Work area is approx 4' W c/1 of 92nd AVE W &
155' N c/I of 216th ST SW to install gas service 1 3x5 paving cut anticipated.
WAS STREET OVERLAYED WITHIN THE LAST FIVE 5 YEARS? YES ❑ NO ❑ Year: 1063
PAVEMENT CUT:
CONCRETE CUT:
❑ Yes ❑ No
❑ Yes ❑ No
If yes, indicate size of cut: 3
If yes, indicate size of cut: —
x5
x
RIGHT-OF-WAY
CLOSURE
AREA
TOTAL
DURATION
(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.
Susan-1 1- sp.d by P,1111 6/14/2018
I d I cK DN at=Susan Sidi[k 1=dilnitlin DepaNnUS ou=Muniapal
SIGNATURE Re1a��'n' emn��-=��=an=d�0700 �nm �-�s DATE
Dee: 2018.06 � 4 13:3fi 28-0�'00'
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Puget Sound Energy Gas Pre -Inspect Form
Job #:
106341236
Date:
6/9/18
Address:
21522 92ND AVE W
Jurisdiction:
EDMONDS
City/Zip:
EDMONDS, 98020
ROW Permit:
Yes
Customer:
HOLLY JACKSON 425-344-6559
Est. Start Date:
8/6/18
PM / Inspector:
Kevin Williams 425-691-7573
Est. Duration:
1 Day
Job Description / Scope of Work
From 2" PE main run new complete 1-1/8 PE service to single family home(12' scat stub with 48' New Construction:
scat extension)set AL-425 meter OR @ Inches No
Construction Method
All Scat / Trenchless
PLAT Map: 164.067 PAL t
N
21518
5/8" M PB
2010-E
CN
Ln
N
5/8" MPEI
2008-E
215 '1
5/8" M PE
1998-E
215191
216TH
ST
SW 22' IL
Work Location
Size of Cut
Surface Type
4'
W
I of CL
192ndAVEW
&
155'
N
of CL
216th ST SW
3x5
Asphalt
of CL
&
of CL
of CL
&
of CL
Service Information
Street Information
Job Type
Diameter:
1-1/8" PE
Flaggers #:
Arterial:
New Residential Svc
EFV:
1-1/8" - 2600 - 9999144
Police #:
TCP:
Yes
PUGET
ENERGY
Meter:
A425
Speed Limit:
25
No Parks #:
6
Meter Loc:
Trolley Lines:
Mtr Hoods #:
Del Press:
6" W.C.
Traffic Signal:
Bus Stop:
Bollards:
2.5" # 1 1 4" # I
ADA Ramps #:1
1 Route #'s:
Puget Sound Energy
Traffic Control Supervisor:
Ina Ustemchuk
Card No. 010768
Card Exp.06/30/2021
ina.ustemchuk@pse.com
(425)398-6063 n
Notes:
1. All signs and spacing to conform to the MUTCD
and City of Edmonds standards.
2. All sidewalks, driveways, exits and egresses
shall be completely clear unless otherwise indicated.
3. Channelizing devices are 28" traffic cones.
Use traffic drums (barrels) with steady burning
Type C lights on all State Routes and Hwys.
4. Sign size can be a minimum of 36" x 36" 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
unless otherwise specified. All work for arterials
and major roadways will be from 9 a.m. to 3 p.m
8. Work area will be 4' WCL of 92nd Ave W & 155' NCL
of 216th St SW.
9. If used, place NO -PARK signs 72 hours in
advance of the day that the work is to be done.
CHANNELIZATION
DEVICE SPACING
MPH
TAPER
TANGENT
55/70
40
80
35/45
30
60
25/30
20
40
PLACE SIGNS ON
•
ALL SIDES OF
WORK AREA
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PUGET
SOUND
ENERGY
JOB# 106341236
21522 92nd Ave W, Edmonds, WA
June 13, 2018
ina.ustemchuk@pse.com
425-398-6063
SHEET 1 of 1
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