1021 BROOKMERE DR.PDF1021 BROOKMERE
DR
CITY OF EDMONDS - SIDE SEWER PERMIT
WATER -SEWER DEPARTMENT
PERMIT b�
Call 775-2525 for side sewer inspections BEFORE covering any portion of the ( construction.) Inspection will be provided within 24 hours after requst. NO Sat., Sun., or holiday inspections./
G4`�7
ADDRESS LOCATION OF CONSTRUCTION ...... /Q.r;�1 ,91 ®6.SC- i� R �,/ - �-��®-����',.•--.----
PROPERTY LEG/•AL_DESCRIPTION ..........v.15'..e��: � IAI eO4'.4....0 -�� . P. ��A...loo,8�... 4-k �..d!�®..�`7"
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......................................................OWNER AND/OR BUR DER---. ......) i>/iP. E"'..........................................
CONTRACTOR'S NAME & ADDRESS ........ ;.... .-•1 -- /� tIi.,_ �. _.. ..........................
t
PSion is granted ............ ................. :.............. _............ 19--....--, for repair and/or connection of a side sewer to the city sanitary sewer
s in accordance with City of Edmonds ordinances. -
f
TION IS CALLED TO THE FOLLOWING:
No. 1—The owners of the property may obtain a permit to construct sewer inside property .line. A licensed Side Sewer Contractor must be employed to construct
side sewer In street area. Do not cover any portion of sewer before it has been inspected.
NOTE Nu.'2—All work performed in city right-of-way requires an Invasion of Right -of -Way Permit obtainable from the City Engineer's office.
NOTE No...3—Obtain full information regarding Ordinance 11.16.030 and Regulations governing side sewers when you get permit.
NOTE Nd: 4—Top of side sewer must have at least 30 inches coverage at property line and 12 inches inside property line; minimum grade of 2%. No bends in grade
sharper than % will be permitted. .
NOTE No. 5—Trenches in street must be water settled and surface of street restored to original condition. Contractors shall be responsible for failure due to improper
work which may develop within one year of completion.
NOTE No. 6—It is unlawful to alter or. do any other work than is provided for in the permit, or to do any work on the main sewer or its appurtenances except to in-
sert the pipe into the wye.
DISAPPROVED❑
Date ... _
................................... By ................
Date.---..............
-............. By- .............
Date ............... _................... By....-...........
APPROVED
- Date..._....._
�,.
.7.
BY..._.........
............._-._.._...........-..............................................._......_..................
j'Remarks: ....... _...... ............................ ...--....................................
...................•-----------•--------------.............._......................................................................................................................... ---................ -......................................
— BOTH Permit Copies MUST Be Signed By Owner of Firm Performing Construction PRIOR To Request For Inspection —
i I-�i�-
........ .. - ....-nstr............. hereby certify that the side sewer installation constructed under this permit
(Owner of ContractingfcrmingConstruction)
41istalled in accordance with all governing ordinances of the City of Edmonds.
Datedthis............................day of ......................................................... ..:; 19.........
J d Check BEFORE you dig for: Water ❑, Gas ❑, Telephone ❑, Power ❑, Sewer ❑, Other ❑ V d
•
ADDRESS:
TAX ACCOUNT/PARCEL NUMBER: 20
b
0 Z 151
b 0
BUILDING PERMIT (NEW STRUCTURE):
i q
-7-1 M
01
(5F
COVENANTS (RECORDED)
CRITICAL AREAS q6 i 1101 DETERMINATION: ❑ Conditional Waiver Study Required []Waiver
DISCRETIONARY PERMIT #'S: !ID -
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED
PERMITS (OTHER):
PLANNING DATA CHECKLIST DATED: 1(1 (4 11 1
SCALED PLOT PLAN DATED:
SEWER LID FEE $: LID
SHORT PLAT FILE:
SIDE SEWER AS BUILT DATED: Z1 -18
SIDE SEWER PERMIT(S) #:�� U 1
GEOTECH REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
WATER METER TAP CARD DATED': -1 I I I i F
OTHER:fj�Nj :jq - I -1 `+" 1 pa,Vj
LOT: BLOCK:
LATEMRDSTs\Forms\Street File Checklist.doc
24I( i l 010
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"Nothing'ip this pe--miL app
el process eb► be
' -
maintenance ;,If any cuprent
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mitting the
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condition which is o
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drawing. Such
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'tion
uilding, stru or
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ieement action,"
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- APPRovED BY PLANNING
ZoneR - 12
Corner Fly
���i�'
�. VED
Setbacks Re utr d Actual
Front E--..�♦
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-To De Ac
JUL 112013
®WNERJCONTRAG TOR IS RE.,PONSIBLE
Sides.N/S 10'
3s
DEVELOPMENT SERVICES CTR.
FOR
EROSION CONTROL AND DRAINAGE
Rear \4 2CITY OF EDMONDS
Other
Height �s-
��5, : STREET FILE
PLANNING .DATA .
SINGLE FAMILY RESIDENTIAL
STREET=FILE
Name: L.
(VIASite
Date:
Address:
Tax Parcel:
Project Description: Re-01.c.e, deck s�•r�':�� I+ dra;1� ,not
dry C-4 ; n 4 u4h;
Plan Check #: $L1b2,0.l307Y9
Reduced Site Plan Provided: YES NO)
Zoning:
Map Page:
Corner Lot: (YES / 0
Flag Lot: (YES /U10
Critical Areas Determination #: GRIk1! 5C5IN9
Study Required .4 S- 'Ce.ate, . See c.ANon � ss �►�d o„ �%S�t3. Atlowcd Pew EGDG23. yv. 310. c .3.
❑ Waiver
SEPA Determination: Exec, t`�—
Exempt
❑ Needed (for over 500,cubic yards of grading)
❑ Fee ❑ Checklist ❑ APO List with notarized form
Required Setbacks
Street: a5
Side:_ (0 /
Side: Cs O
Rear:
Actual Setbacks
Street:
Side: 35 ,
[Side:( l
Rear:
❑ Detached Structures:
❑ Rockeries:
El No
Fences/Trellises: n e_ Sin 0,.> .
❑ Bay Windows/Projecting Modulation:
® Stairs Deck: Ex%eA'qr, cle.c k ko 6e,
Buildin Height
Datum Point:
Datum Elevation: N
Maximum Height Allowed: s
Actual Height: 4
Other
Parking Required: a
Parking Provided:
Lot Area:
Maximum Lot Coverage: 35% roposed: 20
Lot Coverage Calculations: Ex,s4. 44oae, = 1 � . E'`'�' o�`�'= IAPO . _�, ylG 0 : tl ba5=
ADU Created: (YES .NO
Subdivision:
.Legal Nonconforming Land Use Determination Issued: (YES
Comments
20%,
Plan Review By:
Planning Data Form 07-14-09
City of Edmonds
Critical Area Notice of Decision
Applicant:
Property Owner:
Critical Area File #:
Permit Number:
c0.A19 SOI 9
'1
Site Location:
Parcel Number:
to Z per.
�� 031 D011 loo
Project Description:
v
Conditional Waiver. No critical area report is required for the project described above.
1. There will be no alteration of a Critical Area or its required buffer.
2. The proposal is an allowed activity pursuant to ECDC 23.40.220, 23.50.220, and/or
23.80.040. Work cs'�
3. The proposal is exempt pursuant to ECDC 23.40.230.
❑ Erosion Hazard. Project is within erosion hazard area. Applicant must prepare an erosion and
sediment control plan in compliance with ECDC 18.30.
❑ Critical Area Report Required. The proposed project is within a critical area and/or a critical area
buffer and a critical area report is required. A critical area report has been submitted and evaluated
for compliance with the following criteria pursuant to ECDC 23.40.160:
1. The proposal minimizes the impact on critical areas in accordance with ECDC 23.40.120,
Mitigation sequencing;
2. The proposal does not pose an unreasonable threat to the public health, safety, or welfare
on or off the development proposal site;
3. The proposal is consistent with the general purposes of this title and the public interest;
4. Any alterations permitted to the critical area are mitigated in accordance with ECDC
23.40.110, Mitigation requirements.
5. The proposal protects the critical area functions and values consistent with the best
available science and results in no net loss of critical functions and values; and
6. The proposal is consistent with other applicable regulations and standards.
❑ Unfavorable Critical Area Decision. The proposed project is not exempt or does not adequately
mitigate its impacts on critical areas and/or does not comply with the criteria in ECDC 23.40.160 and
the provisions of the City of Edmonds critical area regulations. See attached findings of
noncompliance.
Favorable Critical Area Decision. The proposed project as described above and as shown on the
attached site plan meets or is exempt from the criteria in ECDC 23.40.160, Review Criteria, and
complies with the applicable provisions of the City of Edmonds critical area regulations. Any
subsequent changes to the proposal shall void this decision pending re -review of the proposal.
❑ Conditions. Critical Area specific condition(s) have been applied to the permit number referenced
above. See referenced permit number for specific condition(s).
Reviewer j ature Date
Appeals: Any decision to.approve, condition, or deny a development proposal or other activity based on the
requirements of critical area regulations may be appealed according to, and as part of, the appeal procedure, if any,
for the permit or approval involved.
Revised 1211612010
I
,.-..bF
�aPProvalt rec �a]s���
interpreted as allowin or. permittin 1g t
_ /; maintenance vf' any eu entl existin
' Aenconforming or unp raiitted bui!dia1 structure
M PQ Ki M« er site condition which is outside the a of the
permit application, leers of wheth , such
building, structure or ndition is aho
site plan or draraing. S ch building, st dture W011 on or condition may be the s 'b'ect of
nforcement action." J a separa
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oa '
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. � i � '. 1 ` ,3. to • U.l � . �oR -
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ExST, " x �Dt��o1.1�5�wA �$ozo
PDU5C- ul. �°
C DCC TO TAXZ-103Z�i DOZIS k00
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---- i-rs-r 5izC - 12y 07S7 S&.F:-%-,
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covE17�- Z 41.E SO,F1
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3 m y Z6
APPROVE Zone 3Y PLANNING
Zone RS-1 Corner F1 g
Set acks Ruired ct�.a_l = 'T"
o DeeS� RECEIVED
Front E — 15'. �+
Sides N/s Io3S' JUL 112013
Rear 1,J 1 S ' y � ,
QWi��EsnvlC��i��ir`IC l �� IS �iriF� ��SI �E F�� DEVELOPMENT SERVICES CTR.
EROSION COI TROL !` ^; ; Other CITY OF EDMONDS
A��U D+-�fI�,GE Height c CITY
®��
CITY OF EDMONDS ' - E== U ", 'Permit No. <`
PUBLIC WORKS DEPARTMENT Issue Date
RIGHT - OF - WAY CONSTRUCTION PERMIT APR Z. 3 19X
ip ///////
A. *Address or vicinit of Construction • Permit Issued To:
-_i®2/ ezgeze
• Owner: 711 �N Af zl L=' • Type of Work to be Done: W
N�
s�,!nzzr
Mailing Address
,e dw o vlos . Ah9s "Al
City, State, Zip Code
• Work in Connection Withh:�
El Sub or Plat 11 Single Family
❑ Comml. / Ind. ❑ Apt. Condo.
• Pavement Cut: ❑ Yes C_No
• Contractor:
Name
Sze" S'E .1.?.3-41-A&.
Mailing Address State License Number
�0VP&Q s f�M
City, State, ip ode Telephone Number
* NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE
B. APPLICANT TO READ AND SIGN
INDEMITY: Applicant understands and by his signature to this application, agrees to hold the City of Edmonds harmless
from any 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 it's departments or employees, including or not limited to the defense of any legal
proceedings including defense, costs, court costs, and attorney fees by reason of granting this permit.
Upon issuance of this permit, the contractor is responsible for workmanship and materials for a period of one year
following the final inspection and acceptance of the restoration by the Engineering Division.
Funds held from the Security Deposit (estimated restoration fee) will be held until the final street patch is completed, at
which time a debit or credit will be processed for issuance to the applicant.
Work is to be inspected. Restoration to be in accordance with City Code. Traffic Control to be in accordance with Traffic
Section of City Code. Street to be kept clean at all times. A 24 - hour notice is required for inspection by Engineering. Call
775-2525, extension 220.
I understand that this permit muse avail at the job site for inspection purposes at all times.
* * THIS PERMIT MUST BE POSTED AT THE JOB SIT FOR INSPECTION PURPOSES
CALL DIAL - DIG PRIOR TO BEGINNING WORK
C. Issued $�
Time Authorized: Void after days
Special ndit� i
Ammendments:
..,00
Permit Fee:
Security Deposit: �—
Receipt No.:
Fund 111 Fee:
Street Cut Dimensions
X
WAM
* * NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE * *
Eng. Div. December 1978
Site Information
CA FILE N(
6ritica'l "Ar"e-as Che'c'k,fle'
/vegetation)
14A
1.
Site AddressALocation:
2.
Property Tax Account Numbei:
�Q.qr
3.
Approiiinite Site Size (acres or square feet): "076
is
Q(),t
`4.
4
Is this Wrrently developed? _Y yesV
no.
If yes; how is site developed?
.5.
Describe the general site topography. Check all that apply.
uk Flat: ` jqssthan 5-,feq# y*qn changeover entire
.ns
"I less than 15%"(91fertical'i
frsI*&on4stte-gen y,
horizontal q -6s,�,jkcl
Aisiance.6f 6&feet).
",'�Hilly.,.:-,""-slop�es'p-resent"O"n"-1sitd6"f more than'15% less than 30%,'('W.,hffiW HnW * uf
214fflop :5,v
--of `IO41e,d,over h6 ntal distance of 3116 66-f6et).
'.1
j
.30% present on site (a vertical of
------- Steep es of.gr AM 0 4 6a over a
4C'� Horizontal less than 33-feet),, J* Ci
Other (please describe) ,.,
-4-
C4-
6. Site contains areas of year-round standing water: A40 /Approx. Depth -
Site
NA 7. ins areas 4seasoiial stabding''W'ateir: ;"Approx, Depth:
What season(s) of the year?
4
tj
N,7_
�
8. -Site is isthe'flo6dway, _11o6dplain /VO �O`bf a water couise.`-U zl 1�
C
9. Site creek ek or an area Wheie` water flows across the grounds surf"? Flow S`a_"re year- .
1
round?'Flows' I* , are.seaso (What time of year?.
;-o
10. Site is primarilr. fbrested•
meadow mixed
urban landscaped Qawn,shrubs etc)
A"
If.' JDbv_16"us'w`T@a__n'd i*s--p*r--es—e-n-t*,-6,,n,-site: �--� ----- - -
Z7"
6001
MM.
0
T�
1, 1995
9 0 19 C�
TE City of Edmonds PERMIT COUN
R
Critical Areas -Checklist-.
The Critical Areas Checklist contained and -tubmit' it to thd,City. ne"city-will...
-.this forraj 10,bp any
,person perso 4!. ivub..?,;t!�,reviewAhe checklist,,:make a prei;�!r L sorysite,!�.
Ping a Development. Permit -:nisi-and -make-a: determination of the'.
Application, for''Ahe City
of Edmondstrioi.subsequent stens.nedessmv to.comnlete- a
14
V
"_ to hi s�bidftil ofa developmentpermit
perm tv.
it to the Ci f With'a si �dl , I `the�:.:,, gn pqpyo this &M.
-should hW su mit a vicinity. map 675`1',
The purpose of the Checklist is to enable; b icant
City staff to determine whether any.-.,.----. or plot plan for individual lots of the parcel
potential Critical Areas are or -may be----.---.- -with enough detail that City staff can find
present on the subject property. The and identify the subject parcel(s). In
u
t,- informatiod'-d needed to complete.theaddition the applicant shall ind de. -A,
Checklist should be easily available from other pertinent infonination (i.g'. site
observations of the site or data available.at..__,__-.._._ plan, topography'; I
map, etc.)'or stiidies in
City Hall (Critical Areas tnventones-,'mapsjt' .:Coglunction- with thisr.Checklist-to'asemt
r
or soil surveys)
staff in. completing their,prelimina, Y"
I),
amassment, of the site. .V-,
An applicant; or his/her representative
-
must. fill -out hethecklist,.. signtAnd:date
I have completed the attached;.Critical,Area:Checkliit and:attea-,thattthe answers provided.ari6
factual' Io -the best of•my-knowledge (filltoutthe' Awropr4Wtcolum'n-bel6w)';'Z'�'.'z""
Owner I Applicant: Applicaht R60resintative:
'4 1
Name
Street Address;
APPLICATION
The City of Edmonds for EASEMENT NO . ............................................
SIDE SEWER PERMIT
NEW CONSTRUCTION 0 REPAIRS E] LID NO . ................ ...ASMT. NO. .................
OWNER ... ------ .......... CONTRACTOR ...... c-, PERMIT NO.
JOB ADDRESS .... c---ST- LEGAL DESCRIPTION: LOT NO- -------------------------------------- BLOCK NO. ------------------------------------
----------- ................................... .............................................. �- --- -----
•
NAMEOF ADDITION ........................................................................................................................
DATE....... .............. By --------- ---------------------
0-
i
APPLICATION
The City of Edmonds for EASEMENT NO . ............................................
SIDE SEWER PERMIT
. NEW CONSTRUCTION P,-' REPAIRS ❑ LID NO- ------------------ -ASMT. NO. ------------------
OWNER _.�1 r3C `LL`3f7 `' ��� %---------------------------- CONTRACTOR -- L. Cif /f�11� _ff/------- --- •--- -- PERMIT NO. �._1..�.__L._.
JOB ADDRESS .(-.�"''_ �`d U__-�� G�,f _' 4 LEGAL DESCRIPTION: LOT NO- -------------------------------------- BLOCK NO. ---_-_-_--------_-..---------_-_---.
NAMEOF ADDITION-----------------------------------------------------------------------------------------------------------------------
Approved:
DATE
PUBLIC WORKS DEPART CrEMIST T FILE
BUILDI TG PERMIT
1�2 %JT9
IVY (address)—
to
Street Right -of -Way Existing
REQD
z
Access Easements Existin
REQD
H
1:4
Utility Easement Exist
REQD NA
w
Lot Per Subdivision Plat
Assessor Map
w
Site Plan Checked for Accuracy
2
Underground Wiring Reqd.
.
H
Check Accuracy of Le al Description
(l 4r- q
z
Review by
Date
w
'
Exis ting Water Main Size & < < oN S--o t rN ak_e �.-... e
Water Main Required e�
Service Line Required
Hydrant. Size Existing Q
1:4
Hydrant Reqd Per Fire Code
Size
w
Detector Check Meter Reqd. }�O
Cross Connection Inspection O
H
Fire Department Comnents
3
Water Meter Charge Reqd. 06 3 50 �pj
Review by K(UG
Date t/ %
Septic Tank Design Approved
Date
Septic Tank Permit Reqd.
Permit No.
Sanitary Sewer Availabi 'i�ty
-pro j . L-ID - CJ -;L .
Drawing No. S "
File No. / i ql - 0 -7
Side Sewer Availability
Sanitary Sewer Connection Fee Reqd.
`til
3
Review by
Date I t t S
w
'
Open Ditch Existing ,/4,. e
Reqd. —
Culvert Reqd. ��C�
Size --
c4
Catch Basin Reqd. ���
Indicate on Site Plan—'
o
s
Shoulder dr inage maintain collec i9V on swale open runoff `Q
Manhole re d.
q �{/�
Indicate on Site Plan --
Soil Conditions and Ground Water Field
Checked
Review b t����
Date l/,-
`J
o
Revised: lv10-1977 0
- VSE PERMIT zor+e r NumoEn '707
IC
BUILDING DEPARTMENT Applicant Fill I
PERMIT APPLICATION I inside Heavy Line> roe ADDRESS +/� I) � � / v�
/ a LI(J �- 'L
NAME !OR NAMY OF BU SIN ESSI !f LpT AREq
L" $UBDIV ISION NO.
'7 •^, `A ^' EGAL µLO
�JKC� a YES ONO
C M ILING ADDRESS W ADD,— STREET RJN
--
... 1 EXISTING ST^CET f:jW 5C! FT• DEFICIENCY THIS PROPERTY
^ CITY TELEP NONE NU" COMP. PLAN ST. VOW `-' -
_ DI
t /QN V � 1��`-V ' •✓'�' �_���--_�,_�— REN.ARKS C
NAML- i '
CHECKED BY ` Z
u
• W ADDRESS
F z
_EN
STREET AND/OR UTILITY WORK R/W rF.rR-�MiT REOVIRED Ill
U TELEPHONE NUER REO•D QS Uy� RN"
C CITY 0YPS 9NO
' _ VNDERGROUND I '
NAME wjRiNG REO'D. dyes Ig NO
13
TYPC C�INNECTION -- GYES VERIFIED BY
C / SANITARY SeWCR
O ADDRESS �� ❑NO UMBER
1•
t V v-� ` PERMIT NUMBE=
< TELEPHONE NVMBER SEPTIC SYSTEM ❑ YES
gPPV:D BY Clime EiJG. 12NO
C cITY
a ' ?y-e�Las
z I REMARKS �• �J '
U STATE LICGNS NUm BeN CITY LICENSE NUMBE ^ , i4� `
+� �tt ^/y.� L f 1
f inen 1 Y'� r� 1 I I y McrER $f'L F, ,•But LDII SV PPI_Y 51'GE C
Legal Description of Property (Show oclowJ/o/r�jAt ach Four Copies) F
REMARKS Q 3
A NO.
SIGN AREA ENV. REV14W
PROPOSED COMPLETE I EXEMPT
ALLO:':CD
N
W
D REMARKS
O PANNING EVI BY DATE ,
' W I VARIANCE OR CII �1L
LOT CUVERAG
YARDS
FRONT sloe 'A REAR
❑GAS �r ION CODE HEIGHT
FIRE ZONE 'TYPE �OF CONSTRV ,
Ir NEW RESIDENTIAL LINE •�.�-� T 9 13 �w
• l��- I NON-RESIDENTIAL I 1 SIGrr / [L J •+V
AREA OCCUFANCY OCCIi Fi�NT
❑ iIDD f� SPECIAL IN OR LOAD
: RETAINING GROUP
Der.'DLISH D WALL REOVIRED . V
FENCE X FTI p YES ' NO O_ I
ALTEF LYCAV ATE I.-- _- PU njfHE�Kcp Y THIS $!TE Is LOCATLD IIV . CITY i
❑;iR FILL - /OF EDMONDS. LOCAL SALES TAX
r-1 ❑PRE -MOVE El
..V SHOULDD 1E CODED 31.04.
REPAIF INSP. ROOL EM F
NUMBER OF
NUMREN OF +TORTES DWELLING (\�
.-( �Ly UNITS �• \`.
1
-iNATURE OF WoRA TO BE OONE
VALU.ITION FEE —
PLAN CHECK M_
PROPOSED VSE W
69 u o 0/ 60 0� -- `
y VLOT PLPN (IP'DICATE BV!LUING SETBACKS, BUILOI N+i
ABUTTING Sn'HCETS)
7S
UPLUMBING " W
HEAT & GAS LINE _ —
O �
o _ t
FENCE 1 z
[� D
' SIGN
RETAINING WA,L O
u
SWIM.'AING POOL
!
1 her^!+Y acknowledge that 1 have read this appticatior,: Lra: the in -
TOTAL AMOUNT DUE oz 3J— S
formation given is correct: and :hat I am the-owne% or the duly author-
ized agent of the ovmer. I agree to comply with city and dace lasye regu-
gTTENTION I APPLICATION APPROVAL
lating cons:ructier:: and in doSng the work authorized. thereby, no person r
THIS PERMIT 1 h:$ application is not a permit
µ•Gil be employed in violation. of :he Labor Code oc' the Stare of R`s!hingtion AUTHORIZES I ❑ntil signed by the Building Official or
relatin _ sB:kme .� CP'.npensation Insurance.
nl:.,Inl 1'j10XS and FILL o.NLY THE his Deputy; and fees are paid. and
TE: Farmit Li1.1it One Year(�xceat.._.__
crmi:, which shalt Lr completed in 90 WORK NOTED receipt is ackncwtedged in spat: pro-
PERMITS %,itho co ditio 1-ti1e p' vidCd.
days; 1tOVE ti L' - shat lx con -Meted in six months.) INSPEC T!CN I oR•� $IGNATV ��//,�
UATF_ SIri NECK'] rIEpARTM ENT C��/1- Irk �/�7� 11 (-•
-.GNlL>•:.. �_. � / � i �/ i "'7/
tiDMONOS DATE
Lca Subject to Plan Check Fee .'75-2525 f�__
A'OTE: ApP • _
-- OntGINAL - File YELLOLY - Insp^ctor
This Permit coven vhe ' bli dc.to lil� oinolcurbsa sidRwalks YdrriivewaVs, GOLD - Assessor PINK - Owner
Any construction on the p':
rtLtrquees, etc.) wall require separatr. permiaion.
MakeTap ...............................................................................................................
.............................. 25 ..................................................................... . ....... . ..............
Guar. Voucher N".
m�:ozuzks'
OUTGOING
`6=° ` ~'``
INSTALLA110i
TELFPHONF
CABT,F1 T.V.
Uj
GAS
STORM SEWEIR
FUTURE SERVICE 1NSTL: YE,S (,NO
SURCHARGE: YES NO
DA INITIAL:
UNLOCK
ACCOUNT NUMBER:
HOP
SUPPLT ER:
R
AN
TREATMENT PLANT
0 B 11 T
SIDE -SEWER PERMIT
1�i
TAP CARD
METER SHEET
APPLICATION/
DISPATCH