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1023 C AVE.PDFIIIIIIIIIIIIII 10480 1023 C AVE CITY OF EDMONDS - SIDE SEWER PERMIT WATER -SEWER DEPARTMENT PERMIT � , o' h /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./ ADDRESS LOCATION OF CONSTRUCTION........ nos--.....- ...t.......... .....-n !.. ........................................................................ PROPERTY LEGAL DESCRIPTION......._ I....... r-^-'E� 0� ......-- . U It P...- t..-% , tr-o.•a ................... .` ;� ................ . ....................... _.......................... _...............------._.................................--........---.................................................................................................................................. ................................................................OWNER AND/OR BUILDER .......... � ®-0�{n r e tn.,l I ACTOR'S NAME &ADDRESS.....---......J_. o... �_..... =-. ....--•--.......... .... l.^a• 4.--,c............ ---_....................................................... scion is granted .....- !!\ mac. ...... zr= ...--, 19 r? , for repair and/or connection of a side sewer to the city sanitary sewer systems in accordance with Cityrof Edmonds ordinances. ATTENTION IS CALLED TO THE FOLLOWING: NOTE 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 No._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 regasding Ordinance 11.16.030 and Regulations governing side sewers when you get permit. NOTE No.-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 maln sewer or its appurtenances except to in - Bert the pipe into the wye. i DISAPPROVED❑ Date..._..... .................... By ................ Date.---- .......... By....--...------- Date ............... _................... 'By ................ APPROVED �Date..._�... -. i. ....................... By..._ ---- . .. ................-.._.....................-....-.-...................-...............................------- Remarks: ......._...... _..........................................................................................----................... ........ _.............. BOTH Permit Copi s MUST Be Signed By Owner of Firm Performing Construction PRIOR To Request For Inspection — I,-.......4 .. (� ..... ............ .... hereby certify that the side sewer installation constructed under this permit (Owner of Contracting Firm Performing Construction) was installed in accordance with all governing ordinances of the City of Edmonds. % Dated this.........)1..7.............day of......./..1.01.74CIA .................................... 19,/ -D-. d Check BEFORE you dig for: Water ❑, Gas ❑, Telephone ❑, Power ❑, Sewer ❑, Other ❑ ADDRESS: L 0 2 S "C" Am e+Nu e) TAX ACCOUNT/PARCEL NUMBER: E70( 04001oaa UO BUILDING PERMIT (NEW STRUCTURE):A 37-O4 (oG COVENANTS (RECORDED) CRITICAL AREAS: DETERMINATION: ❑ Conditional Waiver Study Required ❑ Waiver DISCRETIONARY PERMIT #'S: DRAINAGE PLAN DATED: PARKING AGREEMENTS DATED: EASEMENT(S) RECORDED FOR: PERMITS (OTHER): (���IO5�'I n� ��gSO�OZ►�W1P,Ch PLANNING DATA CHECKLIST DATED: SCALED PLOT PLAN DATED: SEWER LID FEE $: LID #: SHORT PLAT FILE: SIDE SEWER AS BUILT DATED: 3' 2. SIDE SEWER PERMIT(S) #: (0021 GEOTECH REPORT DA STREET USE / ENCROACHMENT PERMIT #: FOR: LOT: BLOCK:_Z WATER METER TAP TAP CARD DATED: r'Z OTHER: RW W O' [ZGSfi RDW 0(5 ' L o3 GmsFatl ueAA-) 6AS seemc�) LATEMMDS'N\Forms�Street File Checklist.doc ENNEERING VISIN 0 It, m APPROVED GIAS DINOD e5k- Fro 4.. y . 1Q3 C, 19 "1 fooL p, I Ltrio Applicant shall repeftftv�m Lttigfies or fmftge kv right-of4my per City or occurs duifty ft p~ A —) k r 00 W�00 4-1 ct IX 0.7 5.3o 0 0 p Al 7 No -7 w t 7 t C-0 SO rj C-v v-e 05101 1 Corner Flag (40 ktbaks Required Actual < Fro it Sidi i 7.s 1 -1 tj/-i q s X- 5', Rc) I w r 0 enftfnCft . ...... zsc- L, APPROVED BY PLANNING JAN 0 3 2014 DEVELOPMENT SERVICE7 COUNTER STREET F1L' • USE /1 -7-7 f1 l �- t•� ' BUILDING D E id T Applicant Fill ZONE i PERMIT APPLIC ION Inside Heavy Line - PERMIT �(! /�+ NAME •r (OR NAME OF BUSINESS) /1 j �t // ` ' / 1 GAL LOT S/U�jB�/D�IVIj9y,1�,0yN NO. Jr�I �(/ +LJN It-OREAO Pub; O/`� YIS ONO ` ." C MAILING ^" 'CJ ADDRESS ��7 + [/ EXISTING STREET R/W � � FT. DEFICIENCY THIS PROPERTY ' , C - CIT`: ^ ELEPHONE NVMBER POMP. PLAN 5T. RfW C.Il PT• �FT' 1 z �D owps Z ) �• �' `. NAME REMARKS •' - C 1 � I- )y' lam• 1 ' ,t ` /L W CHECKED ` !E� , V' /'�"�y CHECKED BY W_ W ADDRESS ' R/ W PERMIT NEOVIREU Z �� y Z STREET ANU/OR UTILITY WORK W V C CITY < TELEPHONE NUMBER REDID. REDID. W.NO [I Yes 40 /-t�fauL�5 7i D7 88 I Cl YES ) ' •' UNDERGROUND W NAME WIRING REQ'O. 0YES yp NU , ' C TYPE CI':INECTION AYES VER IFIFD BY • 0 F j ADDRESS / SANITARY SEWER ONO ' < PERMIT NUMBER SE IC SYSTEM ❑YES '- C CITY TELEPHONE NUMBER gPPV'D BY CITY ENG. r D ��•- uI-7ATE CITY LICEr:SE NVMBE: R[MAril(`.'.� [�J'� �, 4-'•_ / / L CENSC NUM BCF V/J`�•C�- }i�) {?� o ( I I I :•'=•• -.. - •.�.: METER SIZE 6V ILD1 SV PPLY SIZE LE al esgrLo f Pr party ;Show Below or Attach Four Copies! SIZE 4 11- -� 1 t r_ D < R R S 1 I 3 L _,vUAr6e- z� PLC '��Y' O 125� �9JJ,fl l7-ID ENV. REVIEW ADO NO. SIGN AREA r F C _L ALLOWED OPOSED COMPLETE EXEMPT U REMARKS k�LIwT .. W �I 1 �•- \r . PLANNING REVI J By DATE. VARIANCE OR ! , „i YARDS LOT COVERAGE /FRONT 1 0SIDE REAR i j '-•i it OAS I�-y 1 JU NEW ' I RESIDENTIAL FIRE ZONE TV PECONEfRUR10N CODE /� I ❑ SIGN 1 ' NON-RESIDENTIAL ADr RETAINING D'ECIAL INSPECTOR AREA OCCUPAN' OCCUPANT /1�0. GROW LOAD '• :�. DEMOLISH REQUIRED �.n WALL N>6 ❑ ,ZNO . • ❑EXCAVATE PENCE — ❑ YES ALTER ❑ po Ti "T) PLAN CH K D BY I ATEV+ SITE IS OLOCAL (SALES TAX OF EDMONDS.S REPAIR OPRa-M-Vs: -WIM SHOULD BE CODED 31.04. 0,00L > INSP, REM KS h NVMBER OF STORIES NUMBER OP J-/�� w/' /Ir la•('�i It S�I(� W I 'Z UNITS UN NATURE OF WORK TO BE DONE C W VALUATION FEE• G0 Z PROPOSED USE PLAN CHECK Z W •QQ. 7. H :1- y NO. -- 0 s/ 0- / 3. PLOT PLAN ,INDICATE BUILDtN GJ,ETBACKS. BUILDING I O ABUTTING STREET J 1 I It III 33 ! U PLUMBING r 7 N W D D HEAT h GAS LINE t D — Y H FENCE "— Z I SIGN RETAINING WALL C U „_ +t;�• SWIMMING POOL DUE g I hereby acknowledge the: I have read this application; that the in- TOTAL AMOUNT l APPLICATION APPROVAL formation given is correct; and that 1 am the owner, or the duty author- I to comply with city and state laws regu- ATTENTION ` ized agent of the owner. agree . lating construction; and in doing the work authorized thereby, no person of the Labor Code of the State ofWashington THIS PERMIT This application Is ❑Ol a permit will be empioyed in violation - Workmen's Compensation Insurer._^. AUTHORIZES until signed by the Euilding Official or relating to NOTE: Permit Limit Ore Year(Escept DEMOLITIONS and P in 90 ONLY THE his Deputy; and fees are id, and pILL receipt is acknowledged in space pro- PERMITS without conditional us: permit, which shall be completed be in six months.) WORK NOTED vidcd. jays- MOVEDIN i;UIL-)INGS shalt completed ys' DATE SIGNED WNER O' AGENT( INsreerloN DEPARTMENT DIRECTOR' SIGN R + - SIGNAT - 2 CITY OF r + �'] r EDMON DSmllwill DATE NOTE: Applicant Subject to Plan Check Fee 775-2525 7 property Permit covers work to be done on privateONLY. ORIGINAL -File YELLOW Insovctor L This (orbs pi sidewalks, driveways, Any construction on the _ marquees, e.lpublic l domain GOLD Assessor PINK - Ow•Lr N • �.n i la. i., Irv. - I V 4- t �J 1&itical Areas Checklisif ----------------------------------------------------------- --- Site Information (soils/topography/hydrology/vegetation) 1. Site Address/Location: i o l I Caeo oa N E Corn r ✓ 2. Property Tax Account Number: 00� 3. Approximate Site Size (acres or square feet): 4. Is this site currently developed? yes; no. If yes; how is site developed? 5. Describe the general site topography. Check all that apply. Flat: less than 5-feet elevation change over entire site. Rolling: slopes on site generally less than 15% (a vertical rise of 10-feet 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: Approx. Depth: 7. Site contains areas of seasonal standing water: ; Approx. Depth: What season(s) of the year? 8. Site is in the floodway _�'%� floodplain of a water course. 9. Site contains a creek or an area where water flows across the grounds surface? Flows are year- round?Flows are seasonal? (What time of year? ). 10. Site is primarily:. forested ; meadow ; shrubs ; mixed . urban landscaped (lawn,shrubs etc) X 11. Obvious wetland is present on site: ^ce chk.doc; Rev 10/03/97 City of itmonds NJU °r CRITICAL AREAS CHECKLIST 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 a development permit 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 .Areas inventories, maps, or soil surveys). An applicant, or his/her 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 to 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 form. In addition, the applicant shall include other pertinent information (e.g., site plan, topography map, etc.) or studies in conjunction with this Checklist to assist staff in 'completing their preliminary assessment of the site I have completed the attached .Critical Areas Checklist and attest that the answers provided are factual, to the ` best of my knowledge (fill out the appropriate column below). Owner/Applicant: MA14crm Dt., RCMM_:�_� Name a1 -1,— 2 Co �o Street Address 617 �04 1 IL11,_12 t. City State Zip 7 7-5) Telephone Signature Date c:receptionljanalcact. doc Applicant Representative: Name Street Address 5�� City State Zip © _ Telep e Signature ,Date (over) PLANNING DATA SINGLE FAMILY RESIDENTIAL STREET FILE Name: 1vlvY-�� i. e� Ltd . Date: ( LV ( s Site Address: 1�. 2 �y���- Tax Parcel:OC)(�,.iCl 40(n> (009 00 Project Description: K�U ����1`� �`� "S Plan Check #: Reduced Site Plan Provided: YE / NO) Zoning: Map Page: Corner Lot: (YES / NO) FFlag'Lot: (YES / NO) Critical Areas Determination #: i" Zo / o 1.0 v a •Study Required . ❑ Waiver SEPA Determination: Exempt ❑ Needed (for over 500 cubic yards of grading) ❑ Fee ❑ Checklist ❑ APO List with notarized form �. Required Setbacks Street: Z 5 'Side:.- { U Side: l �. Rear: 2 O Actual Setbacks Street: 2 5 Side: Side: �-� s Tear:' ❑ Detached Structures: .❑ Rockeries: ❑ Fences/Trellises: . ❑ Bay Windows/Projecting Modulation: ® Stairs/Deck: Buildin Kei ht n/ A - Qc,k h. 1,,j rGO IL� Datum Point: Datum Elevation: Maximum Height -Allowed: Actual Height: Other Parking Required: ►CIA Parking Provided: /1114 Lot Area: �-� 3 Q 3.2, G�� Maximum Lot Coverage: 35% Proposed: I �•� L s . Lot Coverage Calculations: ADU Created: (YES NO Subdivision: Legal Nonconforming Land Use Determination Issued: (YES / Comments•. L t- 4, Plan Review -By: Planning Data Form 07-14-09. CITY OF EDMONDS 121 51h Avenue North, Edmonds WA 98020 Phone: 425.771.0220 • Fax: 425.771.0221 • Web: www.edmondswa.eov DEVELOPMENT SERVICES DEPARTMENT • PLANNING DIVISION 'nc. Critical Areas- Reconnaissance Report ficaLAre'as File' Number a ' d-'M2014,0100 Determination i Study. Required Site;'Loca'tion Tax Account Number 00619400100900 Applicant Same ..� Cr�trcalTAreasvPresent _ 4 Q GeologicdllyHaza�dous :. Erosion Hazard Areas Site Description During review and inspection of the subject site, it was found that the site may contain or be adjacent to critical areas, including Geologically Hazardous Areas, pursuant to Chapters 23.401 and 23.80 of the Edmonds Community Development Code (ECDC). Cited sections of the Edmonds Community Development Code (ECDC) can be found at: http://www.codepublishing.com/wa/edmonds/.. The associated LiDAR map indicates.that the parcel slopes gradually from the east to the west at approximately 25%. Soils underlying the parcel are identified as Alderwood Urban land complex (8% -15% slope). As a result, the areas of the parcel with slopes in excess of 15% are considered to be erosion hazard areas. Determination: Study Required This review applies to the entire subject parcel. Depending on the location and project proposed relative to the identified critical areas, icertain studies and reports, maybe required. Please contact the Planning Division;at 425.771.0220 when you'have a specific development proposal for this site in order to discuss the various permits that will be required. Rg o��5tk5r%� i Ark Covtvro � P,, r tp 00N �111i kA, C I��s'� Lkey\ ►5 vL2�rc' a_5 t I 4p— V S(-" 11 00l� 'P Q #P20 City of Edmonds ., Development Services Department _ Planning. Division . Phone: 425.771.0220 r�� 1g90 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 areas inventories, maps, or soil surveys): Date Received: !' , L4 City Receipt #: Critical Areas File #:U-6110AOLDD Critical Areas Checklist Fee: $155.00 Date Mailed to 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 to 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 form. In addition, the applicant shall include other pertinent information (e.g. 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:tofiLhisapplic ' on the behalf pf the owner as listed below. SIGNATURE OF APPLICANT/AGENT DATE L Property Owner's Authorization By my signature, I certify that I have authorized the above Applicant/Agent to apply for 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 property for the purposes of inspection and posting atten to this applc tion. SIGNATURE.OFOWNER DAM { Z / Ow er/Appli ant:. Applicant Representative: Name Name Street Address o q Street Address City State Zip City State Zip �l Y7 Telephone' Telephone: Email address: �. c ,("p mail Address: Revised on 12118112 P20 -Critical Areas Checklist Page I of 2 J #P20 CA File No: GrQ LD I oc Critical Areas Checklist Site Information (soils/topography/hydrology/vegetation) 1. Site Address/Location: 2. Property Tax Account N Approximate Site Size (acres or square feet): Is this site currently developed? yes; no. If yes; how is site developed? 3. 4. 5. Describe the general site topography. Check all that apply. Flat: less than 5-feet elevation change over entire site. Rolling: slopes on site generally less than 15% (a vertical rise of 10-feet over a horizontal distance %J 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: 0 ; Approx. Depth: 7. Site contains areas of seasonal standing water: ; Approx. Depth: What season(s) of the year? 8. Site is in the floodway _aQ floodplain _ of a water course. 9. Site contains a creek or an area where water flows across the grounds surface? Flows are year-round? Flows are seasonal? (What time of year? ). 10. Site is primarily: forested ; meadow ; shrubs ;mixed urban landscaped (lawn, shrubs etc) 11. Obvious wetland is present on site: ioG 1. 2. 3. 14. 5. For City Staff Use Only ------------- ----------- Plan Check Number, if applicable? Site is Zoned? SCS mapped s Critical Areas inventory or C.A. map indicates Critical Area on site? = Z Site within designated earth subsidence landslide hazard area? A/O SITE DETERMINATION e �v5w� STUDY REQUIRED WAIVER Reviewed bv: Date: CON: ( 7 Revised on 12118112 P20 - Critical Areas Checklist Page 2 of 2 J �L Allowed Activities & Exempt Proposals. Certain activities are allowed in or near critical area buffers as specified in ECDC 23.40.220. f Similarly, certain development proposals may be exempt from Critical Areas requirements (ECDC 23.40.230). However, it is more likely that an alteration to a critical area or buffer will require some form of City review and approval. According to ECDC 23.40.320: "Alteration" means any human -induced action which changes the existing conditions of a critical area or its buffer. Alterations include, but are not limited to:.grading, grading; filling, dredging; draining, channelizin9. cuttin9. pruning, limbing or topping, clearing, relocating or removing vegetation; applying herbicides or pesticides or any hazardous or toxic substance, discharging pollutants; paving, construction, application of gravel modifying for surface water management purposes; or any other human activity that changes the existing landforms, vegetation, hydrology, wildlife or wildlife habitat value of critical areas. If you have any questions about whether your proposed development qualifies as an allowed or exempt activity, please contact the Planning Division.. Building Setbacks Unless otherwise'provided, buildings and other structures must be setback a distance of 15 feet from the edges of all critical area buffers or.from the edges of all critical areas, if no buffers are required. The following may be allowed in the building setback area: 1) landscaping; 2) uncovered decks; 2) building overhangs, if such overhangs do not extend more than 30 inches into the setback area; and 4) impervious ground surfaces, such as driveways and patios; provided, that such improvements may be subject to water quality regulations as adopted in the current editions of the International Residential Code and International Building Code, as adopted in ECDC Title 19. General ,Report Requirements Critical areas reports identify, classify and delineate areas on or adjacent to the subject property that -may qualify as critical areas. They also assess these areas and identify any potential impacts resulting from•specific development proposals. If a specificdeve►opment proposal results in. an alteration to a critical area;.the critical areas report must contain a Page 12 mitigation plan. General mitigation requirements for all critical areas are described in,ECDC 23.40.110, through 23.40.140. Critical area reports are most commonly submitted when applying for a building permit or land use development application but they can be submitted at any time. The minimum requirements for all critical area reports are listed in ECDC 23.40.090.D. There are additional report requirements for specific types of critical areas (see below). Note that it is important for -the report to be prepared by a qualified professional as defined in the ordinance. Erosion Hazard Areas., Development is regulated within Erosion Hazard Areas and must meet specific criteria. For erosion hazard areas with suitable slope stability, an erosion and sediment control plan prepared incompliance ECDC 18.30 will be considered to meet the critical areas "Study Required" determination. The determination -of "suitable slope stability" will be made by both the Planning and Engineering divisions of the City of Edmonds. In areas where the slope stability is not suitable, projects within Erosion Hazard Areas will require a report by a licensed geotechnical engineer or other qualified professional. Report requirements and development standards for alterations within erosion hazard areas are found in ECDC 23.80.050 through 23.80.070. Mike Clu ston Associate Planner October 31 2014 g '0 ' Name, Title Signature Date 1 OC cu4f v : ° Critical Area Map N. 1023 C Ave. 2012 Aerial Photo CRA20140100 1 inch = 75 feet °c. 18913 APPLICATION `the City of Edmonds for EASEMENT NO- ------------------ ------------------------- SIDE SEWER PERMIT NEW CONSTRUCTION REPAIRS ❑ LID NO - ------------------ - ASMT. NO. --------------- OWNER -------�c:)M- E .......... CONTRACTOR ------- V ------ ............... PERMIT NO. JOB ADDRESS � ------------------------- LEGAL DESCRIPTION: LOT NO. ------------- ........ --------- BLOCK NO. ........... A ----------------------- 0 uj .j 14 -------------------------------------------------------------------------------------------------------- ........... ----------------- I ............ By ...... 44-104� -- ------ APPUCATION '7he City of Edmonds I for SIDE SEWER PERAUT EASEMENT NO. . ---------- — ------------------------------ NEW CONSTRUCTION REPAIRS ❑ LID NO. ------------------ - ASMT. NO. -.- ------------- OWNER ... Albi.t4.iw .. 0. ------ P&.44.e.s ....................... CONTRACTOR ---- h6a.l le -el ... 130-e--th-q-0 ------------------- .... PERMIT NO.<:��-- JOB ADDRESS ..... AA ------- try -r ------------------------- LEGAL DESCRIPTION: LOT NO. ---------- ------- -------- ----- BLOCK NO. ....... -------------------------- .......... ........................................................ --------- - ----------------- 7 ---------------------------------------------------------- NAME OF ADDITION ..... Yawl.••-...... ................................................... Approved: N\ DATE --------------- - - ------------------------- By ---------- ---------------------------------------- fi7yg CITY OF EDMONDS ,r PUBLI COORKSOPARTMENT, ENG I•NEEr*, D I10ION APPLICATION FOR RIGHT -OF -MAY CONSTRUCTION PERMIT THIS PERMIT MUST BE AVAILABLE AT THE JOB SITE FOR.INSPECTION PURPOSES Applicant to Complete Parts A and,B A. Permit.to be issued to:_ 2x. — o ,; r. FoWork at:(address or vicinity) Type of Work to be done: it (attach drawing when applicable) r Time Required -- Start: I'VaA'e-A Finish:. A; e- Owner:. Name ` Mailing Addre?s City State Zip Telephone Number Contractor: Name State License Number Mail g Address City State Zip Telephone Number B, INDEMNITY: Applicant understands and by his sign a,ture'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 applicant or the City of Edmonds, or any of its departments br,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 subject to inspection and restoration in accordance with City Code. A 24-hour notice is required for inspection by Engineering. Call 775-2525, ext. 220. I understand that this permit must be available at the job site for inspection purposes at all times. Signature: I L;;- X t.s�- Date: %►%u84 � 11 M7TC Owner or Agent TO BE COMPLETED BY ISSUING. AGENCY: Date Issued: 3 " ` - Permit No.Fee: Security Bond:/G, 1,6r Time Authorized: 3— 1- i 8 SUN 3 C'J' Ai,\ S APPROVED B 10-771v (Revised) Date 3- i —76 W, �2.1 /I 11'e" 0 roc T 41 'PIMLIC ]'!-.PT. .0!1-(-.!, LIST );PILDING, PY11"UT Pj'*V117.' 775-10 STREET fI�E L2z3 "c sr¢ea6 __��ejZ Strcet Pdght-of-Wav 17-xisting A(a b,11:5 Access Utility ol it Fxistin,g Existin.f, IT.09 Lot rcr Suhdivisinn sum— Plat itc Plzui (Tec.l.od for Accurac-.N Anscssor Im) 81-7-7 t C: it Yxistill'- Hydnvlt r-ICr t'jr, .)i ze 9 tCC'LOT (I'.CCI: PC(:Ili r A/0 Fj I C 350 - - - - - -------- -7 L ! lo m i t ? 7o. -74o c , "o. Side Sewer P -t, )!,,,,Vic,.: br /7- ti 0 Catch ;'I.vrim Tjl(I;c.II:c oil 'i':C Mnm C11 C-- � IQ . I-C i ":!I"!)o)e requil-C(I Ildi C.1 oil si.tc "Jail soil C Crolul(,, ;."ater Fich! Ow-c,'�(..; (",)ti.c Tzm!: Cd !i srptjc polvat Pec:,"'i.red uj ...-._Avt-'�! P.q/�r,�p'Ef�-t}_.;,v�•1„nec;sl�i*u�'i..,..`�`§� 'l�.rrt.yv.�`�.I'n.,v+,;,.:.n i,1�•lt:.c,+�§...�r�v"`r9v... , tom. �i�i'f��;'w!i'}4�'•.i , y,, .._.. � ��t:..��r7•� �:-ti. '�`., . City. of. Edmonds FILE )IN --WAY CONSTR MAY 18, 1995 PERMIT -/d ., °s r �Y Permit Number. - ENGINEW-il i l Issue Date: A. Address or Vicinity of Construction: 1023 C Av ( 9516409 ) 18 99 C B. Type of Work be specific): Install New Service,. p-1 C. Contractor: , Washington Natural Gas Contact: Frank Swan Mailing Address: 1 199 75 St SET BvAsett t Phone: 447-3984 State License #: 98203 Liability Insurance: Bond: $ D. Building Permit # (if applicable): h Side Sewer Permit # (if applicable): E. ❑ Commercial ❑ Subdivision ❑ City Project ® Utility (PUD, GTE, WNG, CABLE, WATER) ❑ Multi -Family ❑ Single Family ❑ Other INSPECTOR: INSPECTOR: li..)OC-A F. Pavement or Concrete Cut : ❑ Yes QNo G. Size of Cut: x H. Charge $ APPLICANT TO READ AND SI; f INDEMNITY: Applicant understands and by his signature to this application, agrees 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 t INSPECTION 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. 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 the permit will be available on sittnat all for inspection purposes. Signature: AJ Date: 5-1 0=95 ( On ractor or entJ CALL DIAL -A -DIG PRIOR TO BEGINNING WORK `_ FOR CITY USE ONLY APPROVED. BY: w'^'� t''' RIGHT OF WAY DEPOSIT TIME AUTHORIZED: VOID AFTER DAYS DAYS. SPECIAL CONDITIONS: V,[ ^ `�1` A LOW) _ rA SMAiIJ. COMMENTS: . DISRUPTION FEE/FUND 111: RESTORATION FEE: PERMIT FEE: TOTAL FEE:-'*, RECEIPT FEE:, DATE: ISSUED BY: — NO WORK SHALL BEGIN PRIOR TO"PERMIT ISSUANCE Eng. Div. 1994 .s, M M Washington Natural Gas AW IlwrII(�i t rrv.'rCNCfny iYry N 4 Watermain depth N /P, _?" gas main Q J • Addendum to:. _City.of Edmonds Right of Way Permit Application Submitted by: Hariamne Kingsbury Engineering Aide Washington Natural Gas I356-7500 X7596 Key: -W- -G- -SS- O vc?.%�:Y l.O C-A'C ION Nv Water Gas Sever Water hydrant Water valve Washington Natural (gas Company 1122 751h titrcct `.W.. herctl. WashingUm 98203. (206) 355_3331 JUL ENT 9 -_.. City of Edmonds ---Water ' Department TAP CARD No_.No %eter Tap SSize :.- -•-• ..............-. S le-----------.......---=--.._ Mfgrs. No ................................. ..........._. ty ............. For' ----......:....... _...._....._... - _...: Lot No ......................... Add----------- ................. Service Location ........ Blk. No ......... :................... ...................... Meter Location ................ MakeTap --------- ------------.I..------ Pressure .................... - ........ lbs. Send Bills to -------------- -___..__.- Test ................ .............. _................ _................ _................... ,.... -........ _..... .._:,......... .._._....... -........... ..,. Dateof Work --------------•---•-------•-....... ........................................... -------------------........... ................. ..................... :............................... Foreman Guar. Voucher No .......................... ---............. $.... .......................... .......... Remarks- ............... ............................................................................ :::.:::...... ..... ROUTING SLIP NEW SERVICE INSTALLATION ' AI)DRESS: lk j DATE: �17 7 FORDLAN CREW METER SHOP ?4 DIAL A DIG# Yj;?,2/ P.U.D. TELEPHONE CABLE T.V. GAS STORM SEWER OTHER FUTURE SERVICE INSTL:• YES BORE: SURCHARGE: LOCK DATE: YES INITIAL: ACCOUNT NUMBER: l U 7-0 -7 7 5 U SUPPLIER: CIVIL ENGR. T ATMENT PLANT SIDE -SEWER PERMI DRAFTSI AN E jB L T # uD) CK-----_._.._.._...District PAID 0V 16 Dot i City. of Edmonds ---Water Department TAP CARD Date _....... Z�_� 7...._.... NoMeter Tap� NO......................................... � Size :...... 3�Y"....._ Size .... .......:....... _ Mfgrs. For _... 2 _.. w g __-------. •--_... Blk. No.........I .........---_..------- Lot No . .............. ...........�- Add. ----_. ...:. -------------------- ..................... Service............................. .............. ......................... _.......... ..:....... --------------------------------------------------------•----.......----•----------- -- .... _-_ Meter Location , � 9D g_.... —.................... ....................... Make Tap--•-----=----------------------------------- .......................... -------••-•-•-._.__...---------- ---•••-•--_____-__-_:..... ._..�._.:..:. Pressure-�----------------lbs. Test------.....-•-------------•-=--:....% SendBills to _....- ....................................................... ............................................ Date of Work Guar._ Voucher No,_-______------------------____----- -.:.$.. : ....----................ .... �cc6 .sZz?._ -� ►.r: - .._ St-tt�� Remarks: _R? 2 . r.2.2 .. t C)T_T_'r(.1_l_lT1-TC_1_—Tnclos Reo___Rmrne_Rk-___-____Stenci1_____(1ard---___:_ SUPERINTENDENT I INITIAL:va� DATE: `-If/77