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10611 237TH PL SW.PDFiiiiiiiiiiii4104 10611 237TH PL SW TAX ACCOUNT/PARCEL BUILDING PERMIT (NEW STRUCTURE): COVENANTS (RECORDED) CRITICAL AREAS: l/Z DISCRETIONARY PERMIT #'S: DRAINAGE PLAN DATED: PARKING AGREEMENTS DA EASEMENT(S) RECORDED FOR: PERMITS (OTHER): p(,<sz-w 0 DETERMINATION: ❑ Conditional Waiver ❑ Study RequiredXWaiver PLANNING DATA CHECKLIST DATED:__ SCALED PLOT PLAN DATED:_ In _ I SEWER LID FEE LID #: SHORT PLAT FILE: LOT: BLOCK -- SIDE SEWER AS BUILT DATED: SIDE SEWER PERMIT(S) SOILS REPORT DATED: STREET USE / ENCROACHMENT PERMIT WATER ME'TEERATAP CARD DATED: �\-�p OTHER (2 `�v i7 ` oL>2 I N 1 �-� o2J - 2q- I cVV 9yoW-* qq- Zla ADICk D�- - 14- L:\TEMP\DSTs\Fomns\Su-m File Checklistdoc ,� = ZO. Sc�,1� I C, ti4 s-- 0z Ilk y � Fri ' �'• '_ 4 � � ` �� '`'_ . 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'o u � N m 10629 o O 10707 10620 "" O 10825 0610 CO m 10615 g '4P,s m 10600 10809 1 3 10524 10601 �• 0 f 10522 + 10525 1 n 7 x N � 10506 1 .� O� ` 10517 O O 1 0 10509 CD � 41 • \\ 10507 1 0 10429 1 w 23727 T +/D 6 10319 '� o O` 10307 O Klahaya Pool CL 23726 23718 ;10223 10ftp 1oz1e pA9d OM � o N 23Bt0 ,0214 23719 `10215 e o 24127 24109 N 10273 23911 � � 15 N 230U N 10207 ©' J J e m 70132 10203 10202 10203 $ 4 10201 10202 1020D et 10/24 ypp 10129 10128 10129 y i6 7p � A `6 w � � 10125 10129 10131 t0128 10133 w 10127 70174 101STAVEW VL lone r 10121 10120 tg 10121 �9ZO 101STPLW ,0,21 23n6 z37oz lo,ls e i lobe 1013T AVE:W 24203 rot n 10110 2 101ST PL W 10101 101ST PL W 10102 N 10103 10102 Np 10102 g $ N r N m o S 99 10029 ,0028 N 10028 O 10Z028 23925 1-20 100231 eStov n1 S J m o 1 1oo1e 10015 001e N z3e30001e g 101STAVEW ' 101ST:' W Lp a N m }�Ny U 24208 24126 c t'n 1r1 T 238z3 1'i W AVE T : tl Eit ..e._. .....,�. _ ® N S is S m S m 24127 �+ N g $ FIRDALE AVE 10pTHAVE:yy.: z3ela z3604+ 1 #P20 — Critical Areas Checklist CA File No: Site Information (soils/topography/hydrology/vegetation) 1.. Site Address/Location: 106 1(! PL Sck) 2- Property Tax Account Number. OrAV5060015(000 3. -Approximate Site Size (acres or square feet): s�wz+� 4. Js this site currently developed? _Kiyes, no. 5. 6. 7. If yes; how is site developed? d.,`6jT\(1j4 . KeS Describe the general site topographj Check all that apply. Flat: less than 5-feet elevation change over entire site. Rollifig-'slopes; on site generally less than 15% (a vertical rise of 10-feet over a horizontal distance of 664eet)._' Hilly: slopes present on site of more than 15% and less than 30% (a vertical rise of 10-feet over. a horizonta1dishmce of 33 to 66-feet). Steep: grades of greater, than 30% present on site (a vertical rise of 10-feet over a horizontal distance of less than'33-feet). Other, (please describe): Site contains areas 'of year-round standing water NO Approx.. Depth: i Site contains areas of seasonal standing water: Approx. Depth: What season(s) of the year? 8. Site is in the floodway N floodplain � 0 of a water course. 9. Site contains a creek or an area where wafter flows across the grounds surface? Flows are year-round? Flows are seasonal?. - 1,S 0 (What time of year? 10. Site is primarily: forested meadow .;shrubs mixed urban landscaped (lawn, shrubs etc) J.. 11. Obvious wetland is present on site: For City Staff Use Only 1. Plan Check Number, if applicable? Z Site is Zoned? 3. SCS mapped soil M*s)? 15t4-,)­r_L-o4?A Fa 4. Critical Areas inventory or CA map indicates Critical Area on site? 5. Site widdn desigriated earth -subsidence landslide hazard area? DETERMINATION REQUIRED IWAM rrr `v City, oftdmon,ds Development Services'Department Planning Division Phone: 425.771.0220 Fax: 425.771.0221 The Critical Areas Checklist contained on this form is to be filled out by any person. preparing a Development Permit Application for the City of Edmonds prior. to his/her submittal of the application to the City. The purpose of the Checklist is to enable City staff to determine whether any potential Critical Areas are, or may be, present on the subject property. The information needed to complete the Checklist should be easily available from observations of the site or data available at City Hall (Critical I areas inventories, maps, or soil surveys). Date Receib: `(/ M 10 4— City Receipt #: Critical Areas File Critical Areas Checklist Fee:. 5135.00 DaW Mailed do Applicant A, property owner, or,his/her authorized representative, must' fill out the checklist, sign and date it, and submit it . to. the City. The City ,will review the checklist, make a. precursory site visit, and make a determination of the subsequent steps necessary' W complete a development permit application. Please submit a vicinity map, along with the signed copy of this form to assist City staff in finding and locating the specific piece of property described on this farm.- In addition, the applicant shall include other pertinent information .(egg.. site ; plan, topography map. etc) or studies in conjunction with this Checklist to assistant staff in completing their preliminary assessment of the site. The undersigned applicant, and his/her/its heirs, and assigns, in consideration on the processing of the application agrees to release, indemnify, defend and hold the City of Edmonds harmless from) any and all damages, including reasonable attorney's fees, arising from any action or infraction based in whole or part upon false, misleading, inaccurate or, incomplete information furnished by the applicant, his/her/its agents or employees. By my signature, I certify that the information and exhibits herewith submitted are true and correct to the best of my knowledge and that I am authorized to file this application on the behalf of the owner as listed below. SIGNATURE OF APPLICANT/AGENT�1 7 DATE q- 2 3-y tA Property Owner's Authorization By my signature, I certify that I have authorized to above Applicant/Agent to'apply for to subject land use application, and grant my permission for the public officials and the staff of to City of Edmonds to enter to subject property for the purposes of inspection and posting attendant to this application. SIGNATURE OF OWNER�O � DATE Vwner/AppncanC Applicant Representative: Name P o 6 i 1 �3`7 PL �c,y Street Address l: L H U ti Z)S 9-0 City State Zip Name Street Address City State Zip Telephone: Z d 6- .S� y 6 3 3 7 Telephone: Email address (optional): Am Y, (c) m C4 STPmai1 Address (optional): NaT ifrAU City. MEdmonds Devel%ment Services Depaftment Planning Division Phone: 425.771.0220 Fax: 425.771.0221 The Critical Areas Checklist contained on this form is to be filled out by any person. preparing a Development Permit Application. for the City of Edmonds prior to his/her submittal of the application to the City. The purpose of the Checklist is to enable City staff to determine whether any potential Critical Areas are, or may be, prey on the subject property. The information needed to complete the Checklid should be easy available from observations of ft site or data available at City Hall (Critical areas inventories, maps, or soil scuveys). Date RecMM: 'U7-f 10 t'' City Receipt M - Z J.-2S 5' Critical Areas File M Critical Areas Checklist Fee: $1 S5,2 Date Mailed to Applicant: A property owner, or,Ws&w authorized representative, must' fin out the the eldist, sign and daft it, and submit it to.. the City. The City :will review the checldist, make a. pr ecmory site visit, and . mah: a determination of the subsequent steps neceasers► W complete a develo%m nt permit application. Please submit a vicinity map, along..with the signori copy of this form to.assist City staff in fording. and locating the specific 'piece of property'dencibed on this form.. In addition, _.. the applicant shall include other , pertinent infaarnation . 4-.. sitx . PhM,: �jaAy map, etc.) or studies irk conjunction with this Checklist to assistant staff in completing their preliminary t of the site. The undersigned applicant; and his/her/its heirs, and assigns, in consideration on the Proceg of the application agrees to release, indemnify, defend and hold the City of Edmonds harmless from; any and all damages, including reasonable attorneys fees, arising from any action or infiaetion based in whole or part upon false, misleading, inac emte .or incomplete information furnished by the applicant, hialherlits.agents or employees. By my signatu v, I certify that the information and exhibits herewith submitted are true and correct to the best of my knowledge and that I am authorised to file this application on the behalf of the. owner as listed below. SIGNATURE OF APPLiCANT/AGKNTT _ ---_ ----' DATE �z Property Owner's Authorization By my signature, I certify brat I have authorized the above Applicant/Agent to apply far the subject land use application, and grant my permission for the public officials and the staff of the City of Edmonds to enter the subject prorperty for the Purposes of inspection and posting attendant to this application. Owner./Applicant .DPAN tf AMY W l- e �Aou cF Name, Street Address E � M 0 IL1 `� S t,S,�t� • q k'n ac, City State Zip Applicant Representtadve: . Name Street Address City State Zip Telephone: 2 v 6- S g 6-/ 3 3 7 Telephone: Email address (optional): Am Y, w. Ct CO M C4 s?'Email Address (optional): Iv er #P20 CA File rro q 3 Critical Areas Checklist ° Site Information .(soils/topography/hydrology/vegetation) 1.. Site Address/Lotion "A o 6 1 t 3`? P L S w z Property Tax.AccountNumben QO(M500005Co©O 3. Approximate Site Size (acres or square feet): 9,1593 54,, 4. . Is this. site currently developed? ,� yes; no. If yes; how is site developed? 5 � �'Ct,i71 i Lt ucS , S. Describe the general site topography. Check -all that apply. , , Flat: less than 54eet elevation change over entire site. Rolling. slopes on site generally less than 15% (a vertical rise of 104 et over . a horizontal distance of 66-feet). Hilly: slopes present on site of more than 15% and less than 30% (a vertical rise of 10-feet over a horizontal distance of 33 to 66-feet). Steep: grades of greater than 30% present on site (a vertical rise of 10-feet over a horizontal distance of less than 33-feet). Other (please describe): 6. Site contains areas of year-round standing water. MO Approx. Depth: 7. Site contains areas of seasonal standing water. 1U ; Approx. Dep&- What'season(s) of the year? 8. Site is in the floodway N 0 floodphdn N O of a water course. 9. Site contains a creek or an area where water flows across the grounds surface? Flows are year-roundT . N C"� Flows are seasonal?, N 0 (What time of year? ). 10. Site isipAmariiy. forestedT meadow : shrubs : mixed X : urban landscaped (lawn, shrubs etc) 11. Ois:'present on site: For City Staff Use Only 1. Plan Cteck Number, if applicable? Z Site is Zoned? 3. SC5 mapped soil type(s)? _M4:rFt;lf L-OAAA 0-- 8 4. Critical Areas inventwy or C.A.'map indicates Critical.Area on site? 5. Site within designated earth,subsidenm landslide hazard area? a InC.189v May 26, 2004 CITY OF EDMONDS 121 5TH AVENUE NORTH • EDMONDS, WA 88020 • (425) 771.0220 • FAX (425) 771-0221 Website: www.ci.edmondsma.us DEVELOPMENT SERVICES DEPARTMENT Planning • Building • Engineering Dean & Amy Whitehouse 10611 237u' Place SW Edmonds, WA 98020 Subject: Determination regarding Critical Areas Checklist: CA-04-63 Dear Applicant: Enclosed please find a copy of the Critical Areas Checklist you submitted. . GARY HAAKENSON MAYOR The 'DETERMINATION" reached by the City is located on the reverse side of the form (bottom of page). IT 1S VERY IMPORTANT FOR YOU TO RETAIN A COPY OF THIS CRITICAL AREAS "DETERMINATION" FOR YOUR RECORDS. Please examine this Determination for additional requirements. You may need to submit additional information such as an Environmental Checklist or Critical Areas Study. The Determination for the. Critical Areas Checklist you submitted is a site -specific determination, not a project -specific determination. Permit applications include the following: Building Permits Conditional Use Permits Subdivisions Variances Applications to the ADB* Land Use Applications Any other development permit applications. Thank you, Planning Secretary *Architectural Design Board Enclosure D:myd ocuments/spellman/CACLietter.doc L:tempfjana/CACLletter.doc • Incorporated August 11, 1890 • Sister City - Hekinan, Japan MAR-10-2004 WED 02:30 PM SNO CO PDS FAX NO. 425 388 3872 P. 03 ADPLICATI• FOR RESIDENTIALABUi�DyNG & MmNICAL PERMIT A I Ii 4 DATL ,T PHONE.,NL" •t10HE` OWNER � r —r :, r �/c /�y /Y;► dTY \�Da 21P CODE C AOUREtS. IJ < G {� C :PHONE- NUMBER C' 'ADDRE,SS .. '� ' - ' "✓ C-I'TY •21P CODE a or . �•CONTRACTOR S"STATF;'ICENS,E:'NON SEPTIC TAPK. :;aDDR,ESS; OF.,J00 _�C�i�: c7 3Z`, P�C1TY rJ ZtP CODE TrfE Ok`WORK _ e�.).J CC�R>��C'SZ- WIDTH OF ROAD DRIVEWAY PERMIT NUMB_ 1..•sp�i'i.ay.v'ra�-rrwr lrw•IrY�1ra•rrwrf ArrrArfa,a..arf+++AVa++rrfaAfrrara�aa+ir+aa, fil,_YYR�frrarwtf•ff, TAX ACCOUNT NUMBER LEGAL,;DESCR�,Ip,T1ON: SUBOIv;1.SI0N;OR.SNORT. ,PLAT -\V ��dP.S�GI]l�'SEC �Jo TWP�'i RGE _ 2DNI4G'R 1b��'BLOCK L07 OR .PARCEL s LOT .SIZE ]6TH RCE18JtCK'S. FRONT ` '' �C . r., �� L� • Q-*#sS ri ADDITIONAL C07` REQOI:RMENT$ for-ofti'te SIIDE C� IS THE-:AVERAGE,SLOPE-OE THE:DRO usr onl ` * PERTY IN: -EXCESS OF'290 y REAR. n 2, Q`!:.� YES- - NO �arar.rr aArr+�Airirrra r;►*i+r*+r#sir►.ra.r.r�. t;x I U1.LOING5 `ON: TH1.S PROPERTY: -� •". i'i�i`a .•a �`✓a#.r raa�a#�Arrr+•rr.fr rlrrjr t,lWf#rrfrr rrr rwrf if♦rwf#M+f Af,Aa rafANwr+Ya+rir_+a11 Aa+jar++f"Y YES y1,� IltluN tilts: --MAIL FLOOR SO. F7.�,STORIES _85MT NO ./> SECOND FLOOR F7.T CC(1NO.li�ii(?k�.UIM: 4pa> nt)h-t SQ. FT, IN BASEMENT.(.include garage in located in bast+nent) [, IAN,.ruln �' HAS CONSTRUCTION STARTED? PLEASE CHECK ONE YES; _ N6' F 000001SF.D STRUCTURE IS TO BE USED FOR THE FOLLOWING PURPOSES % oa�-�� 7777 AP - ..:�.,;'..y.:•..r...v•ar•a irrr•rrrrrrraaarr,�+r#•rr#fir Yr++#.a+f+a+Awra7Yatara+aafa�Aa•tarirr��+aw�va+ri M'4NICAI 11CRMI_T: OIL GAS ELECTRIC LPG _._. ._ NOTE: PLAN CHECK FEE MUSf:`BE PAID; Y WHEN PLANS .ARE SUBMITTED; :NR lY11[ M L'QU,IPMENT FEE T6r aTr—s"Sys-terns IIT(1 KW a• 3 O SIGNED: CONTRACTOR I u,:l '.forage iankes -- i.to •in jaI ions _ OWN ER• + .0PAt PUMP ]198(jk*VAL R OFFICE USE ONLY PLEASE.: Floe Standing Firepl TION:to Wend St.nveCHECK FTY NUILING PERMIT FEE: --..._.......__._ r OQ " MECHANICAL PMT. FEE: r —' _ -- TOTAL DUE: �' Permi( .2 U J. w'BUILDING PERMIT; NO -_99 °:�,,'Tutal'nua .�".V ..fie•, _ , 9. .. ,. �'T`' MAR-10-2004 WED 02:28 PM SNO 00 PDS FAX NO. 425 388 3872 P. al Snohomish County Planning & Development Services 3000 Rockefeller Ave,, M/5 #604 Everett, WA 98201 Phone: (425) 388-3311 Fax: (425) 388-3872 RECEIVED MAR i 0` .2004 FAX7PROP1ENT SRVCESCTR.n F EDMONDS To: Phon . Fax hone: _ ` p Date: Number of pages in cover sheet: 3 From: Records Room Phone: (425). 388-3622 Fax phone: (425) 388-3872 1\\StreetTalk\Data@Com-Dev@SnoCo\SHARED\OPS\Leanne\Records Room f=axtcloc N WT M TY; C OU �W�Aptoj%MIN IS ELDG' mhk 0 NO C� .S 8-299-0631 WASHINGTONKbHows�i COPN 9MI-259-V35 Gy. SEV oqrwm< .EVER Nw UK r9ACMAM LXlt�* Lp. Typt'OfFLIELL YfPM1VT.fEESFEES BUIIOEF . TYPE a toulp am stvx tc4u,110N. $dL AIRC(jIN0'ljP4i 10611- 2,37ifi S' rAmOft NVIsIotuS%c!.qrt"TF toT ILA-':^ 0 • tor MOCK kMliaD'MQ SYMA& il U. M LA z 1, 36A 3 AINr~A MLrRm GRAVIM VSnMS�O-T-U- M LA ACCESSORY LDING -bdmt . FpCtU. Rba4 Wk4bm-& I U. hk LWBIKG vwPEWIT QfCrD 41 U. CAPPORr UNIT KATIP 0 T-U RNACf REAR •EVAPORATIVE �C�0(111AS oTtIER cl Na es MOOMS 5V(CIAL 0151AKUWIA ' OrHu bul LO MIN) ACCCPJ . I - I I .. . YENTILARONFAN RANGE 610M - VALRICtAl.) WNW (eft 16T14 SEC-0 �PILAH 041� AIPHANQLVir ryMOF 011y I PECno?�* DIM. slomes Fu4i STORAGE IANx (GALL A Cay _�' um N wl In bi* IN ROO 2 w FT. 2N D FLOGw 5Q; Fl. &AS16M.EM PLAM_ c 14FM i 1:111001, 11 jjj� CgmE'fLM Am Exj VAlU - ADADIN pf "A"'y fa TOIAt FK USED R rIs SVIA LA. LQ'M 5K 2W rJ t!W T-�0Pet, -rl w e 119.97 ti� EXt Si M. 1pS— -Zone PS -13 Corner PS Flag /Ua Setbacks Re uired Actual ' Front S lI T Sides L" 7---�_ac L-lq'-_d,�_ Rear -7 6't T Other /e la(cf/I i e>rsT;n� ✓lay-t>1�d�, .1__7 Heiaht 26' 5y.oy S6 . BUILDING J U N 2 g 2004 a N PPROVE BYPLANNING 7111oll --;Ty COPY 4,41,11eklwie /,Z // 23�'�Sly Ah"le euMI�w &Ctk- PLANNING DATA NAME: i T U DATE: ? l O N SITE ADDRESS: (DAII ;k371Z Place S w PLAN C K#: 14 -A 6 PROJECT DESCRIPTION: tce Oc s" cow r i .T w e i t v.-Pn t f e., S Fnw -ree s0-&AcK f REDUCED SITE PLAN PROVIDED? O / No MAP PAGE: 00 CORNER LOT: & No FLAG LOT: ffes No ZONING: -� CRITICAL AREAS DETERMINATION #: ()y - 63 ❑ Study Required: kWaiver ❑ Conditional Waiver SEPA DETERMINATION: ❑ Fee ❑ Checklist ❑ APO list w/ notarized form ❑ (Needed for 500 cubic yards of grading, Shoreline Area- site within 200 ft. of Puget Sound or Lake Ballinger) % Exempt -i SETBACKS: Cd Required Setbacks: a ' - SS;Jr"T Street: a5� Left Side: 6 Right Side: �S Rear. { Sw"Ci<5 Actual Setbacks: r r a� Street: I I Left Side: _Right Side: as Rear: Street map checked for additional setback required? Y0i No /DNA LU DETACHED STRUCTURES: 13 ROCKERIES: o K FENCES/TRELLISES: BAY WINDOWS / PROJECTING ODULATION: C Q% ��rj1�s �►I,ev!/ STAIRS / DECKS: ��`��` � OC T - jT- i O K 51 ACC I W� / e�('aC?r� a r" r - 7 ;Aeil - 0/ "" . ry t PARKING: Required: Actual: LOT AREA: LOT COVE IRAGE: NO C Calculations: BUILDING HEIGHT: Datum Point:_ 4 i Zj Datum Elevation: Maximum AI12wed: _ Actual Height: A.D.U. CREATED?: No Yes SUBDIVISION: A LEGAL NONCONFORMING LAND USE DETERMINATION ISSUED: es No OTHER: NewBPPIanningData.FornLDOC . —_ s.'1^-"-,...—+w tJ..+u•.- ... -, _ ., � .�. r . v_• `+rr , t � }6x. Yyl"it T � v'tir,' .r r . ,. `S.-'�r ., r ..•,pit City " U,Edmon =' RIGHT-OF-WAY CONSTRUCTION PERMIT Permit Number. — A Issue Date: A. Address or Vicinity of Construction:1 d 6 (4, n c. 1.8 9 0 B. Type of Work (be specific): dZJ PA -If 2b kg�-� (_4F wz a- G,C) , C. Contractor: Mailing Addres'- 3-7-7 t.�. T State License #: D. Building Permit # (if applicable): Contact: r, 6 j� tc�in L S Phone: Ct 2 <_ — 7 -7 i7 & 1� Liability Insurance: Bond: $ Side Sewer Permit # (if applicable): E. ❑ Commercial ❑ Subdivision ❑ City Project ❑ Utility (PUD, GTE, WNG, CABLE, WATER) ❑ Multi -Family ❑ Single Family ❑ Other INSPECTOR: INSPECTOR: 1# i F. Pavement or Concrete Cut: fflYes ❑No G. Size of Cut: 5- x H. Charge $ APPLICANT TO READ AND SIGN INDEMNITY: Applicant understands and by his signature to this application to 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 or not limited to the defense of any legal proceedings including defense costs and attorney fees by reason of granting this permit. THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL INSPEC- TION AND ACCEPTANCE OF THE WORK. ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREET PATCH IS COMPLETED BY CITY FORCES, AT WHICH TIME A DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT. Two sets of construction drawings of proposed work required with permit application. A 24 hour notice is required for inspection. Please call the Engineering Division, 771-0220. Work,and material is to be inspected during progress and at completion. Restoration is to be in accordance with City Codes. Street shall be kept clean at all times. Traffic Control and Public Safety shall be in accordance with City regulations as required by the City Engineer. All street cut trench work shall be patched with asphalt or City approved material prior to the end of the working day; NO EXCEPTIONS. I have read the above -statements and understand the permit requirements and the pink -copy of the permit will be available on site atpR times for inspection urposes. R Signature: Date: 'l — / Z- �9 Contr ctor or Agent) CALL DIAL -A -DIG PRIOR TO BEGINNING WORK FOR CITY USE ONLY APPROVED BN': --v RIGHT OF WAY FEE:! QQ TIME AUTHORIZED: VOID AFTER 3 O DAYS SPECIAL CONDITIONS: ! DISRUPTION FEEIFUND 111: REST RATION FEE .I T OTAL FEE: RECEIPT NO.: I-^- /'1 ISSUED BY :' _,/LL,1a'C _ e,1 NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE Eng. 1997 FIELD INSPECTION NOTES (Fund 111 '- . Route copy to Street Dept.) Comments CONTRACTOR CALLED FOR INSPECTION ❑ YES ❑ NO Partial - Work Inspection by P.W.: Work Disapproved By:. Date: FINAL APPROVAL BY: Date: 0 ."", . . v 0 7—(2--q9 �oJ S,,-Oo�5 890 _ 19C'- , Cifv of Edmon* RIGHT-OF-WAY CONSTRUCTION PERMIT Permit Number. 1l1-04,,2 Issue Date 3 — Z �— 9k A. Address or Vicinity of Construction: 10611 237 Pl SW (9610161) B. Type of Work (be specific): Install Service C. Contractor: Washington Hatuaal Gas Mailing Address: 1122 75-St Spa Ev-nett State License #: 98203 D. Building Permit # (if applicable): Contact: Marianne Kingsbury Phone: 356-7500—K7 596 Liability Insurance: Bond: $ Side Sewer Permit # (if applicable): , E. ❑ Commercial ❑ Subdivision ❑ City Project ® Utility (PUD, GTE, WNG, CABLE, WATER) ❑ Multi -Family ❑ Single Family ❑ Other INSPECTOR: INSPECTOR: F. Pavement or Concrete Cut : ® Yes ❑No G. Size of Cut: x H. Charge $_ 1 _cut ) APPLICANT TO READ A _4 'SIGN /9 w INDEMNITY: Applicant understands and by his signature to this application, agrees iq hold'?'he 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 or not limited to the defense of any legal proceedings including defense costs! and attorney fees by reason of granting this permit. THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR AIPERIOD OF ONE YEAR FOLLOWING THE FINAL INSPECTION AND ACCEPTANCE OF THE WORK. ESTIMATED RESTORATION FEWILL BE HELD UNTIL THE FINAL STREET PATCH IS COMPLETED BY CITY FORCES, AT WHICH TIME A DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT. Construction drawing of proposed work required with permit application. _ .. A 24 hour notice is required for inspection; Please call the Engineering Division, 771-0220. Work and material is to be inspected during progress and at completion. Restoration is to be in accordance with City Codes. Street shall be kept clean at all times. Traffic Control and Public Safety shall be in accordance with City regulations as required by the City Engineer. All street cut ditches shall be patched with asphalt or City approved material prior to the end of the working day; NO EXCEPTIONS. I have read the above statements and understand the permit requirements and the pink copy of thepermit will be available on site at all times for inspection purposes. Signature: Date: 3-22-96 (gntractor or ent) CALL DIAL -A -DIG PRIOR TO BEGINNING WORK FOR CITY''USE ONLY APPROVED BY: I_%� � �4 JH RIGHT OF WAY DEPOSIT TIME AUTHORIZED: VOID AFTER 04.AY gl,�DAYS DISRUPTION FEE/FUND III: SPECIAL CONDITIONS: W d COMMENTS:r� DATE: RESTORATION FEE: PERMIT FEE: 3 O O TOTAL. FEE: 0 U RECEIPT FEE: ISSUED;BY: NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE Eng. Div. 1994 s FIELD INSPECTION NOTES Comments• Diagram CONTRACTOR CALLED FOR INSPECTION Partial Work Inspection by P.W.: Work Disapproved By: FINAL APPROVAL BY: (Fund 111 - Route copy to Street Dept.) ❑ YES Date: Date: ❑ NO w ` G Awb9igbn(rw WCarV" Watermain depth " gas gain Addendum to: City of Edmonds Bight of Way Permit Application Submitted by: Mariamne Kingsbury Engineering Aide ICY,o PL Washington Natural Gas #356-7500 .X7596 VV Key: -Y- Water -G- Gas -SS- Sever I& Water hydrant p Water valve ,i :�c Washington Natural Gas Company 1122 75th Street S.W.. Everett. Washington 98203. (206) 355-3331 . N MahxidGas AVft gbnErwWGoTV" Addendum to- Cit of Edaonds n Watermain depth " gas main f� N y Bight of Way Permit Application Submitted by: Marianne Kingsbury Engineering Aide 10(D P L Washington Natural Gas i356-7500 .X7596 W Key: -W- Water -G - Gas -SS- Sever I& Water hydrant p Water valve Washington Natural Gas Company 1122 75th Street S.W.. Everett. Washington "203. (206) 355-3331 J "`"MHng0 (rWWCOTV " Addendum to- City of Edmonds Natermain depth " gas main N Bight of Way Permit Application Submitted by: !Marianne Kingsbury Engineering Aide 10(o P L Washington Natural Gas 0356-7500 .X7596 W Key: —W— Water -G- Gas -SS- Sever -& Water hydrant p Water valve Washington Natural Gas Company 1122 75th Street S.W.. Everett. Washington 98203. (206) 355-3331