ENG20160400.pdfSTATUS: ISSUED
CITY OIF EDMONDS
121 5TH NORTH - IDM ND A 8020
5 AVENUE O O S, W 9
PHONE: (425) 771-0220 - FAX: (425) 771-0221
*PERMIT MUST BE POSTED ON JOBS , *
ENG20160400
Permit Number: ENG20160400 Expiration Date: 07/18/2017
Job Address: 9114 207TH ST SW, EDMONDS Location: 9126 MAIN ST
APPLICANT ("ONTRACTOR
SNOHOMISH COUNTYPUD SNOHOMISH COUNTY PUD
GO ANDERS DAHL C/O ANDERS DAHL
P.O. BOX 1107 ' P,;O. BOX 1107
EVERETT, WA 98206 EVERETT, WA 98206
(425) 783-4342
LICENSE #: EXP:
.JOB DLSCRIPTION
Block 1 lane to work on AT&T site on a PUD pole. Traffic control only,
Work at the site to be completed under;BLD20161287.;
SIDEWALK: ( OXO) DURATION IN MONTHS: 0 FEE: $0.00 STREET DISRUPTION TRENCH CUT: ( O X 0 )
PARKING: ( 0X0) DURATION IN MONTHS: 0 FEE $0,00 YEAR OF OVERLAY: 0 FEE: $0,00
ALLEY: ( 0x0 1 DURATION IN MONTHS: 0 FEE; $0,00
INDEMNITY The Applicant has signed an application which states 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 ofils departments or employees, including but not limited to the defense ofany legal proceedings including defense costs and
attorney fees by reason ofgranting this permit.
THE C O NTRAC TO R IS,RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD O F O NE YEAR`FO LLO W ING THE FINAL
INSPECTION AND ACCEPTANCE O F THE W ORK:'
• 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
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 constructiondrawings of proposed work are required with the permit application.
71SAMPPI
CALL DIA1rA-DIG (1-800-424-5555) BEFORE ANY EXCAVATION;
CALL FOR INSPECTION (425) 771-0220 EXT. 1326
24 HOUR NOTICEREQUIRED FOR ALLINSPECTION REQUESTS
C12nklt a P
RELEASED BY
Q FILE COPY
SPACE PROVIDED.
lay, nly, I/I-9/2017
❑ INSPECTOR COPY
Printed: W
DATE
APPLICANT COPY
18.2017
ENG20160400
• Restore ROW to City standards
• Restore Landscape to like or better conditions.
•, Call for locates of undergroundutilities prior to any excavation,
• Alert affected residents and/or businesses prior to work start.
• Conform to approved working drawings and Traffic Control plan.
• 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 Edmonds traffic 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 aresult of construction activity are exempt fromthe noise limits
of ECC Chapter 5.30 only during the hours of 700amto 6:00pm on weekdays and 10:00am and 6:00pmon Saturdays, excluding
Sundays and Federal Holidays. At all other times the noise originating from 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 ofhis 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
whatevernature, arising directly or indirectly fromthe issuance of this pen -nit. 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.
• E -Traffic Control
• E•Engineering Final
PARTIAL INSPECTION DATE: IMTIAL: NOTES:
PARTIAL INSPECTION DATE: INITIAL: _ NOTES:
FINAL INSPECTION APPROVED' DATE: INITIAL:
.., oa Eb&ie",.
ljvc . I i�' O
SEP 2 3 2016
DEVELOPML-NT SERVICES
100008603
ROW PERNIIT NO.: ENG l
ISSUE DATE:
RIGA T -O ` Y r A A CONSTRUCTION
PERMIT APPLICATION
PROJEC."I NAME . i CONTACT:
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CONTRACTOR
Fax #:
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State License #: Email #: � �. .f .I... _ �.......
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Liability Insurance Boarc_., e,. --mm_, _ _ _
Cit Business License #: �
ADDRESS O.R IN CF RS1sCTION Ol' CONSTRUC l tt�4
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SO
WORK
ROW ASSOCIATED WITH THE FOLLOWING TYPE _
_..��..�.� �_... � � .-. .SOI+ PROJECT:
,
Conunercial Subdivision Cite Project Traffic Control (Only)
❑ Alulti-Family ❑ Single Family ❑ Other
EUC (.PU), VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permits
.2, 1), es ❑ Na
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-------------------------
DESCRIPTION OF PROPOSED WORK (Be ,Specific) : Nac (,a ry -{
HIN Z HE LAST TI � ---
WAS STREET OVERLAYED WIT,
VE 5 YEARS YES NO Cj Year:
PAVEMENT CUT: ❑ Yes ❑ No If ,yes, indicate size of cut: X.
CONCRETE CUT: ❑ Yes ❑ No If ,yes, indicate size of cut: —x
APPLICANT TO READ AND SIGN
NINemrluNYmoWul%M'��'d�.uwm�irvmN'NmI�WWlwl'4'y'�'w,mriMsmmm...V.iri� iM�mmdu wvw�mwrww�ww"��wVl wWvwrua� YaYaY iYmtkA ...:':0'.'....,. r...,....ywU"M�tiCwk4Yk^wiCiikpk�'4(///GYrM�/(�f�l�fiYlm"Ep�w'J2M1tt�o0V.�roMIWA,'�IL.,GYeRRNk6Y1BeC.4rtl%lYINdW:ImYW,M,WNF:.'GdYJN'"Lr,S�'L�W'tll'.'GrarvAX[
*Traffic control and public safety shall be in accordance with City regulations as required by the Cite
Engineer. Every fiagger must be trained as required by (WAC) 296-155-305 and must have certification
verifying comhletiorr of the required training in their possession.
*Restoration is to be in accordance with City eodes and Stanclarcls. All street -cut treneh work shall be
hatched with asphalt or City al)proved material prior to the encl of the workday —NO EXCEP'T'IONS.
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 maybe 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 undetstaml the permit t•equirements and acknowledge that I must
Follow all requir'cments k,vorrler for the pc ditt y to be valid.
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SIGNATUItI t DA'1'L+ _ ..._.,
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Contractor ot• Agent
NO WORK SHALL 13EGIN PRIOR TO PERMIT ISSUANCE
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AT&T EDMONDS RIDGE SN63
:�d, CONSTRUCTION OPERATIONS AND ENGINEERING REQUEST
1818 Rev. 11/98
TO F'E�OM
LYNNWOOD 3/2016
DAT
mVnV L 425 512 7706 9/2
ANDERS DAH
9126 MAIN ST (208TH ST SW) EDMONDS / 19(27 4) R ..
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ADDRESS/LOCATION/POLE NUMBER
3 13 264884
1"dQRK ORDER N0.. ,. ,... �._ .._._ TASK N0..._......� .
454--5H 100008603 0030
I MINE
PLEASE ASSIST AT&T WITH THE MODIFICATION OF THEIR CELL SITE
POLE HEIGHT: 50' AGL
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mer service for Customer work CUSTOMER EW HOURS
Vilien completed, Coll
the I)J)D at 425-783-1000
_•, �....-..y�_rc .._ _. ..... _._ or (1-877-783-1000) ask
Customer Signature Date for Energy Control Dispatch
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APPROVII DY COMPLETED ByJDATE
hustribuVon: V I Oe, ortmenl Respaas+tato For Work-flaturn To Originator Completed Blue-GIS, 03, After Work Completion
C roryj eparlmenl flespons;We For ftrk-File Copy Pink-Originolor