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PROJECT NAME: 107053987
CONTRACTOR: PSE/Infrasource
Mailing Address: 1660 Park Lane, Burlington, WA 98233
State License #: INFRASL871C2
City Business License #: N R-023614
CONTACT: Sue Sidick
Phone #: 425-457-6353
Fax #:
Email 4: Susan.Sidick@pse.com
F-1 Liability Insurance El Bonded
ADDRESS OR INTERSECTION OF CONSTRUCTION: 1045 2nd AVE S
ROW WORK ASSOCIATED WITH THE FOLLOWING TYPE OF PROJECT:
F1 Commercial 0 Subdivision 0 City Project Ej Traffic Control (Only)
F-1 Multi -Family X Single Family F-1 Other
F-1 EUC (PUD, VERIZON, PSE,
COMCAST, OVWSD):
Is this permit part of a blanket permit? El Yes W No
� ANY ASSOCIATED PERMITS? BLD# ENG#
DESCRIPTION OF PROPOSED WORK (Be Specific) : Work area is approx 18'W c/1 of 2nd AVE S &
approx 260-401'S C/1 of Pine St. (4) 2x5 paving cuts anticipated.
I WAS STREET OVERLAYED WITHIN THE LAST FIVE (5) YEARS? YES El No El Year: 107@j
PAVEMENT CUT: X1 Yes F-1 No If yes, indicate size of cut: 2 x 5
CONCRETE CUT: [j Yes F-1 No If yes, indicate size of cut: _x_
RIGHT-OF-WAY DURATION
AREA TOTAL
CLOSURE ___:r(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 Sidick
SIGNATURE �°._ as
S
�«p,s��o,s,�-0 DATE 04/18/2017
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE