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CITY <br /> �"'� Washington State Utility Accommodation Application <br /> VI/ Department of Transportation �— <br /> (Permit or Franchise) <br /> Utility Contact Information CLEAR FORME �5'' <br /> Utility Company Utility Contact Name , <br /> City of Everett Public Works Department Randy Loveless, P.E. S <br /> Email Phone(Office/CeIlNoicemail) <br /> rloveless@everettwa.gov (425)257-8825 -- <br /> Location (www.snagmp.com) <br /> State Route Milepost Begin Milepost End County <br /> SR 5 194.8 194.8 Snohomis <br /> Installation Submit the Following Documentation: <br /> Please Check One Please Check All That Apply Utility Facility Description (UFD) <br /> ❑Power ❑Sewer ❑Buried Plan Sheets <br /> ❑✓ Water ❑Telecommunication ❑Aerial <br /> For Additional Documents Applicable <br /> ❑Gas ❑Surface Feature(Pole, ped,vault) to your work, see Submitting a Utility <br /> ❑Other ✓l Attached to a bridge/structure Accommodation Application Webpage(Link) <br /> E. <br /> Describe Installation Type(Briefly explain) <br /> The City of Everett owns an 8-inch ductile iron pipe water main that crosses the Snohomish River via Bridge 5/645W. The original Ch <br /> bridge design included the water main and attachments to the bridge piers and bridge superstructure. After noticing the water main ..-j <br /> was leaking on the south end of the bridge,the City attempted to repair the water main under Maintenance Agreement GMB-1165, <br /> signed by WSDOT on 3/12/2020. When attempting the repairs on 3/13/2020, it was discovered that anchors attaching two of the �--, <br /> water main support brackets to the concrete bridge pier had failed,and need to be replaced prior repairing the water main. The <br /> attached design is for the repair of the water main and the replacement of failed concrete anchors. -1 <br /> Jul 13,2020 1 week c <br /> y <br /> Anticipated Construction Start Date: Project Duration: <br /> Billing Information* (R' <br /> Contact Name <br /> City of Everett Public Works,Attn: Randy Loveless c <br /> Street <br /> 3200 Cedar Street <br /> City State Zip+4 <br /> Everett WA 98201 <br /> Phone(Office/CellNoicemail) Email W <br /> 425-257-8825 rloveless@everettwa.gov <br /> Federal Tax ID Applicant Reference Work Order(optional) , <br /> 91-6001248 202-0858 <br /> CP <br /> Utility Authoriz igna <br /> Signature nn Name&Title/Owner Date <br /> Cassie Franklin, Mayor CP/Zd 11-- <br /> The Authorized Signature indicates the General Provisions, as provided, have been read and are agreed to by the Utility.The <br /> Utility understands, based on the proposed installation, applicable special provisions will be provided at issuance of your Permit or <br /> Franchise. <br /> *WSDOT has the authority to invoice the Utility for all work associated with the review, processing and inspection of the proposed <br /> installation.The applicant promises to pay any additional costs, in addition to the fees, incurred by WSDOT in accordance with WAC <br /> 468-34 and RCW 47.44. <br /> Supplemental Contact Information of Authorized Agent if NOT the Utility AT ST <br /> Company Name Contact Name za <br /> Ci y Clerk <br /> Email Phone (Office/CeIlNoicemail) <br /> Offi�PPPe of the City AttcrneY <br /> ROVED AS To FO M <br /> DOT Form 224-696 Dav d C.Hall,City Attorney <br /> Revised 06/2019 <br />