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ROW PERMIT NO.: ENG 11=,
ISSUE DATE:
RIGHT-O&WAY CONSTRUCTIO11
PERMIT APPLICATION
PROJECT NAME: 887026340
CONTRACTOR: PSE/Infrasource
Mailing Address: 1660 Park Lane, Burlington, WA 98233
State License #: INFRASL871C2
City Business License #: NR -019840
CONTACT: Sue Sidick
Phone #: 425-457-6353
Fax #:
Email #: Susan.Sidick@pse.com
❑ Liability Insurance F Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 716 7 AVE S I 0J 6t ao `U -- 00-tZ
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F1 Commercial 0 Subdivision [I City Project 0 Traffic Control (Only)
❑ Multi -Family N Single Family F] Other
F-1 EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? ❑ Yes R* No
ANY ASSOCIATED PERMIT BLD# ENG#
...............
DESCRIPTION OF PROPOSED WORK (Be Specific) : Permission requested to repair cross bore
and restoration for patch work area was approx 25'S c/l of Hemlock & 8'W c/l of 7th AVE S.
eeo,;c ek c,'I" ��rw"
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES E] NOE] Year: 887@i
PAVEMENT CUT: X1 Yes F1 No If Yes, indicate size of cut: 3 x 5
CONCRETE CUT: El Yes El No If yes, indicate size of cut: X
RIGHT-OF-WAY
DURATION
AREA]LF
TOTA]SF
(NUMBER OF MONTHS)
CLOSURE
Sidewalk 48 Hrs + LF
X
Alley 72 Hrs + LF
X
Parking 72 Hrs + LF
X
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.
SDATE 09/O7/2016
SIGNATURE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE