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ENG20140445.pdf01, X 7 'N' ........ . CIT h0mu lis 1215TH AVENUENORTH - EDMONDS, WA 98020 PHONE: (425) 771-0220 - FAX: (425) 771-0221 *PERMIT MUST BE POSTED ON JOBS TE STATUS: ISSUED ENG20140445 RIGHT OF WAYPERM IT (6-E[,JC) Permit Number: ENG20140445 Expiration Date: 08/13/2015 Job Address: 7110 210TH ST SW, EDMONDS Location: City Wide Ne ject PUGET SOUND ENERGY Hydromax USA LLC 6500 Ursula PI, S a PO BOX 97034 FAC BELLEVUE, WA 98009-9734 % (502)851-6513 LICENSE #: HYDROUL870JS EXP: 04/22/2015 City wide cross bore study-CCfVpipebe inspection of City Sewermains and laterals, cross bore study with Puget Sound Energy. _ ° 0 -, ASSE'S'SED VALUE: $0.00 PROPERTYA A: 0 ,SIDEWALK: ( OXO } DURATION IN MONTHS: 0 FEE: $0,00 STREET DISRUPTION TRENCH CUT: ( 0 X 0 } � !PARKING: ( 0X0) DURATION IN MONTHS: 0 FEE: $0 00 YEAR OF OVERLAY: 0 FEE: $0.00 ALLEY; I, 0X0 I DURATION IN MONTHS: 0 FEL' $0 00 INDEMNITY.- The Applicant has signed an application which states he/she holds the City of Edmonds harmless from injuries, damages or claims ofany kind or description whatsoever, foreseen or unforeseen, that may be made against the City of Edmonds or any ofits departments or employees, including but not limited to the defense ofany legal proceedings including defense costs and attorney fees by reason ofgranting this permit. THECONTRACTOR IS RESPONSIBLEFOR WORKMANSHIP AND MATERIALS FOR A PERIOD OFONEYEAR FOLLOWING THE FINAL INSPECTION AND ACCEPTANCEOFTHEWORK. • Traffic Control and public safety shall be in accordance with City regulations as required by the City linginecr. Every 11aggermrlust be trained as required by (WAC) 296-155-305 and must have certification verifying conipletion of the required training In their possesion. • 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) BEFOREANY EXCAVATION CALL FOR INSPECTION (425) 771-0220 EXT. 1326 24 HOUR NOTICEREQUIRED FOR ALL INSPECTION REQUESTS TIES AP PLICA11ON IS NOTA PERMITUNT'IL SIGNED EY'I"E CITY E:NGWEER OR HISMER DEvPUTY: AND FFsES ARE PAID, AND RE3CEIP'TTS ACKNOWLEDGED IN SPACE PROVIDED. BY Printed: Wednesday, August 13, 2014 DATE "�II l+";COPY INSPECTOR COPY APPLICANT COPY STATUS: ISSUED ENG20140445 • If any repairs need to be completed on the sewer lateral and/or main line, a separate permit will need to be obtained by the contractor completing the work. All repairs will need to be inspected by the City of Edmonds. If all repairs will be completed by 1 contractor, we can issue one permit for the life of the Hydromaxpermit. The City would add additional inspection fees as needed for each repair. • A traffic control plan for those designated areas will be required for review and approval prior to any work being completed. A inspection fee will be added to the permit and an inspection is required. Please note that any area where there is a need for a police officer, the police officer must be a City of Edmonds Officer. To request the officer, contact Linda Mack at 206-650-2809, 10 days prior to the start of work. Please also note that any work on Edmonds Way and Highway 99 will require a lighted arrow board. • Restore ROW to City standards Restore Landscape to like or better conditions. • Call for locates of underground utilities prior to any excavation. Alert affected residents and/or businesses prior to work start. • Conform to approved working drawings and Traffic Control plan. • Verify clear bore crossings • Utility patch restoration to be in accordance with Edmonds Standard detail E2.3 • Maintain erosion & sedimentation control. Keep street clean. • Call for required inspections as noted. • Traffic Control per approved plan and MUTCD. Refer to City of Eclimnds tratfic control requirements. • Applicant shall repair/replace all damage to utilities or frontage improvements in City right-of-way per City standards that is caused by or occurs during the permitted project. • Sound/Noise originating fromtemporary construction sites as a result of construction activity are exempt fro of noise limits of ECC Chapter 5.30 only during the hours of 7:00amto 6:00pm on weekdays and 10:00am and 6:00pm on Saturdays, excluding Sundays and Federal Holidays. At all other times the noise originating i'iom construction sites/activities must comply with the noise limits of Chapter 5.30, unless a variance has been granted pursuant to ECC 5.30.120. • Applicant, on behalf of his or her spouse, heirs, assigns, and successors in interests, agrees to indemnify defend and hold harmless the City of Edmonds, Washington, its officials, employees, and agents from any and all claims for damages of whatever nature, arising directly or indirectly fromthe issuance of this permit. Issuance of this permit shall not be deemed to modify, waive or reduce any requirements of any City ordinance not limit in any way the City's ability to enforce any ordinance provision. • 1rTraffic Control • ErEngineering Final PARTIAL INSPECTION DATE: .. INITIAL: � NO"[ ES: PARTIAL INSPECTION DATE:—_ IMTIAL: NOl F : FINAL INSPECTION APPROVED DATE _ fMTIA1 :�ITIT_w_m -1 OF EDAIn. ROW PERMIT NO.: ENO o' , ISSUE DATE: IGHT�OF-�AV CONSTRIJCTION PERMIT APPLICATION PROJECT NAME: CONTRACTOR: Mailing Address: State License #: City Business License #: 0(D0109 5IS CONTACT: Phone #: �( 5-t 1 Fax #: .._......... S��� G. ....... .......� Email #: ��� 1 Su ► 1 i-F��M �/"� ✓Liability Insurance Bonded ADDRESS OR INTERSECTION OF CONSTRUCTION: ROW WORK ASSOCIATED WITH T#:E FOLLOWING TYPE OF PROJECT: El Commercial Subdivision a City Project Traffic Control (Only) ❑ Multi -Family ❑ Single Family ❑ Other �EUC (PUD, VERIZON, PSE, COMCAST, OVWSD): Is this permit part of a blanket permit? ❑ Yes ❑ No ANY ASSOCIATED PERMITS? BLD# __ ...... ENG# DESCRIPTION OF PROPOSED WORK (Be Specific) : C CI\/ P i Paid s-,; P/ Li ZL,` , _. WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES [ NO � Year: . ....._ .._._. ... . _ _ MN__ ........... PAVEMENT CUT: CONCRETE CUT: R Yes F� No If yes, indicate size of cut: x E] Yes 2r No If yes, indicate size of cut: x RIGHT-OF-WAY DURATION AREA TOTAdSF CLOSURE (NUMBER OF MONTHS) Sidewalk 48 Hrs + LF X LF _ .�...i....Alley 72 Hrs + LF X LF arking 72 Hrs + LF X LF 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 , p be valid. �. m or�er or the permit to DATE follow all requirements SIGNATURE Contractor or Agent NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE ACC>J?�-ryy DATE (MMIDD/YYYY) 1 CERTIFICATE . O �` LIABILITY INSURANCE CE 1/3/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and Conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTNAME; Cindy Spu.rlock Torian Hofmann and Dillow Insurance PH(812) LA rf -Xe(812)424-eoLe 3000 Division Street E-MAd ,,,,��L ,, ciradv@ttadfins. com Evansville INSURED Hydromax USA, PO BOX 70 IN 47711 LLC; Hydromax Plumbing Inc., ACincinnati Ins Co B:Cincinnati Casual D: CHANDLER IN 47610 1 INSURER Fri F r0VFRAr,Fs rFRTIFIrATF NtIMRER:CL141308284 REVISION NUMBER - THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. fLTR TYPE OF INSURANCE p u,v'., POLC Y NUMBER riuu nn„iSUBAYyvvvi P Y LXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X CDAMAGE OMMERCIAL GENERAL LIABILITY TO RENTE PREMISE /F epi $ 100,000 A CLAIMS -MADE 111 OCCUR .PP0225623 1/4/2014 1/4/2015 MED EXP (Anyone person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OPAGG $ 2,000,000 POLICY X PRO. Ll LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 000. 000 X AUTO -_�1... BODILY INJURY (Per person)$ AANY ' ALL OWNED SCHEDULED PP0225623 1/4/2014 ,1/4/2015 BODILY INJURY (Per accident) $ X AUTOS AUTOS X NON -OWNED PROPERTY DAMAGE $ `Eer arridenll HIRED AUTOS AUTOS Medical navmenis $ 51000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 AGGREGATE $ 3,000,000 A EXCESS LIAB CLAIMS -MADE DED RFTEIMON$ 0.00 EPP0225623 ,1/4/2014 1/4/2015 R B WORKERS COMPENSATI ON NC2127870 1/4/2014 1/4/2015 WCSTATU- oTH- X Tl1DV 1 IKi1TC Mo AND EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 1.000.000 ANY PROPRIETOR/PARTNER/EXECUTIVE Hydromax USA OFFICER/MEMBER EXCLUDED? (Mandatory In NH) N/A C2127871 1/4/2014 1/4/2015 EL. DISEASE - EA EMPLOYE' $ 1.000.000 If yes, describe under DESCRIPTION OF OPERATIONS below romax Plumbing y 3 E.L. DISEASE -POLICY LIMIT $ 1 , 000.000 A Equipment Floater 4PP0225623 1/4/2014 1/4/2015 Leased $250,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) The city of Seattle is listed as an additional insured with regards to the general liability coverasge with respect to a wriitten contract with respect to any street use permit issued by the city of Seattle. Coverage is primary and non-contributory. A 30 day notice of cancellation given. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Seattle Department of Transportation ACCORDANCE WITH THE POLICY PROVISIONS. 700 -5th Ave Shite #2300 AUTHORIZED REPRESENTATIVE Seattle, WA 98124-4996 Randall Albin/CLS ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGES Ref # Description Coverage Code Form No. Edition Date Underinsured motorist combined single limit UNCSL Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 1,000,000 Ref # Description Coverage Code Form No. Edition Date Uninsured motorist combined single limit UMCSL Limit 1 Limit 2 ELImit Deductible Amount Deductible Type Premium 1,000,000 Ref # Description Coverage Code Form No. Edition Date Premium discount PDIS Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Expense constant EXCNT Limit 1 Limit 2Limit 3 D�eductib�IeAmo�unt Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Experience Mod Factor 1 EXP01 Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date WC & Employer's liability WCEL Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 100,000 500,000 100,000 Ref # Ref Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage a Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Des11 cription Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount w Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium OFADTLCV Copyright 2001, AMS Services, Inc.