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S01 19 2016
ROWPE1VV1ITNO.:ENGZ
ISSUE DATE:
RIGHT-OF-WAY CONSTR.0CTI ON
PERMIT APPLICATION
PROJECTNAME: 186573911
CONTRACTOR: PSE/Infrasource
Mailing Address: 1660 Park Lane, BUrlinglon, WA 98233
State License fl: INFRASL8711G2
City 1311sillesslAcells": NR -019840
CONTACT: Sue Sidick
Phone g: 425-457-6353
Fax #:
Susan, Sidick@pse,com
E] Liability Insurance ❑ Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 7238 212 ST SW
--- ..._..
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
ECommercial Er, Subdivision
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❑ City Project
❑ Traffic Control (Only)
Multi Family FS] Single Family
LA Other;
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EIA -1 JIVD, VERIZON,P'SE,
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COMCAST, OVWSD):
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Is this permit part of a blanket permit?
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ENGII___
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,DESCRIPTION OF PROPOSED WORK (Be Specific) : _Emergency gas leak repair
work took place at approx 286' W c/l of 72 AV \N & 28' S c/l of 212th ST SVT Work has been completed
work was done in soft surface
WAS STRFET OVERLAVED WITHIN THE LAST FIVE (5) YEARS? YES -[]—N47 ❑ Yeal': - 118
PAVEM ENT CUT
CONCRETE CUT:
F1 'Yes El No
Yes [ I No
If yes, indicate size of cut:
If Yes, indicate size of cut: --X---
RIGHT-OF-WAY AREA
AREA TOTAL
CLOSURE (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 aclalowledge that I must
follow all requirements in order for the pe nit to be valid.
SIGNATURE �.� �_ DATE 09/19/2016
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE