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1033 9TH AVE S (2).PDFIIIIIIIIIIII 9910 1033 9TH AVE S APPLICATION for SIDE SEWER PERMIT OUTSIDE ❑ INSIDE ❑ REPAIRS ❑ ___ - ---` '- =- ` ....... CONTRACTOR STREET ---�--•---------------- AVENUE LOT No. ...... NAME ADD . ................... -Fhe City of Edmonds 01VNER ROUSE No. •... a�� ..... 417 BACKFILL WORK ORDER ISSUED` .. ..... DEPOSIT $............... SEWER WORK ORDER ISSUED ________________________________________ CARD No- ------------ EASEMENT No_ _______________ PERMIT N `1 ........................................................... BLOCK No........................................�- ......--•--------_._----•-.. •...•-•----•----. Approved: r DATE ...........' -... ..........r t BY CITY OF EDMONDS SINGLE FAMILY ADDITION/REMODEL COVER SHEET Directions: Applicants are to complete the information in the WHITE BOXES ONLY (Shaded boxes N• 10(vi,1i,:ues only). This cover sheet must accompany each building permit application for a single-family reeldential add111ooksmo4ol project. ElFAX CORRECTIONS MAIL CORRECTIONS E•MAIL;CORRQCTIONS BY SIGNING THIS STATEMENT I UNDERSTAND THAT I AM THE CONTACT PERSON FOR THIS PROJECT. IT Is MY-"ISPONSIBILITY TO COORDINATE ALL SUBMITTALS WITH THE CITY AND ONLY I CAN MAKE INQUIRIES ON THE STATUS OF THE APPLICATION. I UNDERSTAND IT IS MY RESPONSIBILITY TO DETERMINE IN ADVANCE OF PERMIT SUBMITTAL ANY DISCRETIONARY PERMITS THAT MAY BE APPLICABLE TO THIS PROJECT. I ACKNOWLEDGE THAT TO THE BEST OF MY ABILITY I HAVE SUBMITTED ALL NECESSARY DOCUMENTATION IN ORDER TO MAKE A COMPLETE APPLICATION AND NO DISCRETIONARY APPROVALS ARE REQUIRED. SIGNATURE `ZONING INF.PRMATIONy ZONE �� LOT AREA .NUMBER OF DWELLING UNITS EXISTING DEMOLISHED PROPOSED L;UemplbullQing%lormeUdd_rvw.vsd 7/00 ENGINEERING:;INFORMATION DRIVEWAY SLOPE % GRADING CYD'S EASEMENTS jP?Ze"dfa- EXISTING IMPERVIOUS AREA CONSTRUCTED BEFORE 1977 SOFT EXISTING IMPERVIOUS AREA INSTALLED 1977 OR LATER SQ.FT. PROPOSED NEW NET IMPERVIOUS SURFACE SO.FT. BUILOINO CONSTRUCTION INFORMATION CODA QDITI,ON4� 1997 UBC, UMC, UPC, WSEC, VIAO WITH AMENDMENTS DE8101-4-7t-4 ® j WIND EXPOSURE B WIND SPEED 80 MPH SEISMIC ZONE 3 Floor Live Loader Roof Snow/Live Load_ Balcony Live Load Floor Dead Loader Roof Dead Load / C Balcony Dead Load NUMBER BASEMENTS FLOOD ZONE LOT SLOPL:lI,SOILS REPORT PROVIDED YES NO F en,y CITY OF EDMONDS SINGLE FAMILY ADDITION/REMODEL COVER SHEET Directions: Applicants are to complete the information in the WHITE BOXES ONLY (Shaded boxes are for City use only). This cover sheet must accompany each building permit application for a single-family residential addition/remodel project. APPLICANT PLAN CHECK # ��� DATE RECEIVED PROJECT ADDRESS (p73----, pl PROPERTY TAX ACCOUNT PARCEL # DESCRIPTION OF WORK OWNER • PHONE -7%C4 -%2� =:2 CONTACT PERSON PHONE E-MAIL FAX MAILING ADDRESS FAX CORRECTIONS a MAIL CORRECTIONS E-MAIL CORRECTIONS BY SIGNING THIS STATEMENT I UNDERSTAND THAT I AM THE CONTACT PERSON FOR THIS PROJECT. IT IS MY RESPONSIBILITY TO COORDINATE ALL SUBMITTALS WITH THE CITY AND ONLY I CAN MAKE INQUIRIES ON THE STATUS OF THE APPLICATION. I UNDERSTAND IT IS MY RESPONSIBILITY TO DETERMINE IN ADVANCE OF PERMIT SUBMITTAL ANY DISCRETIONARY PERMITS THAT MAY BE APPLICABLE TO THIS PROJECT. I ACKNOWLEDGE THAT TO THE BEST OF MY ABILITY I HAVE SUBMITTED. ALL NECESSARY DOCUMENTATION IN ORDER TO MAKE A COMPLETE APPLICATION AND NO DISCRETIONARY APPROVALS ARE REQUIRED. SIGNATURE DATE to •- 'ZONING I ORMATIO_N ZONE �-0 LOT AREA 1O� 000 NUMBER OF DWELLING UNITS EXISTING DEMOLISHED PROPOSED DISCRETIONARY APPROVALS CA 9)-7?t Determination ,,�,,rc,- SUBDIVISION CU _ VARIANCE SHORELINE -- SEPA ebeoyr Expires OTHER LOT COVERAGE INFORMATION EXISTING SF _l�1`� PROPOSED SF TOTAL SF HEIGHT CALCULATION INFORMATION DATUM A B C D AVE MAX /g ACTUAL SETBACK INFORMATION REQUIRED FRONT y , SIDE -7. SIDE 7. 5 REAR /S`• PROPOSED FRONT 971 SIDE /o SIDE q q ' REAR 3,�, CNR. LOT ❑ YES ❑✓ NO FLAG LOT YES [3NO ST. DEDIC. [:]YES ©NO FT. ADU STATEMENT REQUIRED YES [DNO RECORDING # STAFF COMMENTS: L:ltemplbuildinglforms\Add_rvw.vsd -- 7/00 ENGINEERING INFORMATION DRIVEWAY SLOPE % --- GRADING CYUF— EXISTING. IMPERVIOUS AREA CONSTRUCTED BEFORE 1977 EXISTING IMPERVIOUS AREA INSTALLED 1977 OR LATER PROPOSED NEW NET IMPERVIOUS SURFACE 3iGY> EASEMENTS /lIze"9fg' Cn CT cn CT SQ.FT. (City Use Only) SIDEWALK REQ'D 1:1 YES NO DRAINAGE PLAN REQ'D 13YES]E] NO LID# UNDERGROUND WIRING REO'D [:]YES ❑ NO STREET DEDICATION JJO FT. STAFF COMMENTS: BUILDING CONSTRUCTION INFORMATION CODE EDITIONS 1997 UBC, UMC, UPC, WSEC, VIAQ WITH AMENDMENTS DESIGN CRITERIA WIND EXPOSURE B WIND SPEED 80 MPH SEISMIC ZONE 3 Floor Live Load Roof Snow/Live Load �25 Balcony Live Load Floor Dead Load Roof Dead Load % Balcony Dead Load NUMBER OF STORIES BASEMENTS FLOOD ZONE LOT SLOPE % 010 - SOILS REPORT PROVIDED ❑ YES El NO VIA, FLOOR AREA (Measured to face of exterior wall) Existing Proposed Total Living Space Garage Carport Deck/Cov. Porch Other (City Use Onlvl Ceiling Insulation Window U-Value Wall lnsulation <Glazing U-Value Floor Insulation % Door U-Value sulation Prescriptive ❑ Target ❑ Systems Whole House Ventilation System Req'd ❑ Yes ❑ No Any request for modification; variance or other administrative deviation (herinafter "variance") must be specifically called out and identified. Approval of any plat or plan containing provisions which do not comply with the city code and for which a variance has not been specifically identified, requested and considered by the appropriate city offical in.accordance with the appropriate provision of city code or state law does not approve any items not to code specification. PERMIT ISSUANCE APPROVALS (City Use Only) PLANNING REVIEW & APPROVAL DATE CONDITIONS OF APPROVAL: ENGINEERING REVIEW & APPROVAL CONDITIONS OF APPROVAL: DATE I BUILDING REVIEW &APPROVAL( �� ..�� DATE kl CONDITIONS OF APPROVAL: PLANNING. DATA NAME: 4-" H, /+e SITE ADDRESS: (03 3 - 9 TM S- DATE: ZONING: P—S - R PLAN CHK#: Oo - 133 PROJECT DESCRIPTION:_ CORNER LOT Yes/No) FLAG LOT Alo (Yes/No) SETBACKS: Required Setbacks: Front: 25' Left Side: 7.5' Right Side: `7, S Rear: 15 ' Actual Setbacks: fi carte Front: 97, LeftSide: to, Right Side: g4' Rear: 38' �6r` Street map checked for additional setback required? r,--) (Yes/No) �,S LEGAL NONCONFORMING LAND USE DETERMINATION ISSUED N (YIN) VP Maximum COVERAGE: �Z�f, s>)t�s.u� t(Skao) t(362) Maximum Allowed: 3S7o Actual: �o,��a s• BUILDING HEIGHT: . Maximum Allowed: 1 s' Actual Height: $' -i Datum Point: Mar �jwvtA . Datum Elevation: A.D.U. CREATED?: N. SUBDIVISION: �— 19 63 f c; CRITICAL AREAS SEPA DETERMINATION: ^ter c•. e!;# M,N LOT AREA: 73`f I4k,S - OTHER: Plan Review By: 204z c.Ti1es*rmitNp1amlaLdoc A I UTY so X? J_ 93 ONSIBLE FOR ,MNEPjcot4TRA 8ESP ES AC S �OA "'TROD` -AND DRAINAG� ER ERMA 1PW1W&4_ 5me - 144 i. ROVED DATE: ACV +U-Skewer's C)G. 0"IT11"Al- no+ -44 -tv 0-A P L R Fdi �T NUMBER 74 Q_L Q r- x �.j ox �ttsF CD, C Any 'request for mo(lirlc&tiong variance or other** administrative devial ion (hereinafter "variance") must be specifically called out and identified. fram WA Y Approval of any plat or Plan containing ►Cr� provisions which do not comply with city code and for which variance has not been specifically identified, requested and considered by the appropriate city oircial in accordance with the appropriate provision Of city code or 0-1 state law does not ap rove any items not to code specification. log RECEIVED 4*1 N OCT .0 2 2000 a -rel? DEVELOPMENT E S CTR. DEVELOPMENT C 0 1 OFt S 9 A V " PD. 7 IL t CA FILE NO. Q3 -2-1 Critical Areas Checklist Site Information (soils/topography/hydrology/vegetation) 1. Site Address/Location: %0.33— 9--l' ,joc�f�i 2 WWIn In/? _ 2. Property Tax Account Number: _26-�270_ 000 3. Approximate Site Size (acres or square feet): POO 4. Is this site currently developed? _Ryes; no. If yes; how is site developed?�/rc_ 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: NO ; Approx. Depth: 7. Site contains areas of seasonal standing water: Approx. Depth: What season(s) of the year? 8. Site is in the floodway--2(,0_ floodplain ___&_ of a water course. 9. Site contains,�c�reek or an area where water flows across the grounds surface? Flows are year- round? _ f� 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: For City. staff Use Only------__ 1. Site is Zoned? 2 SCS mapped soil type(s)? Wetland inventory or C.A. map indicates wetland present on site? 4 Critical Areas inventory or C.A. map indicates Critical Area on site? S: Site within designated earth subsidence landslide hazard area? 6. Site designated on the Environmentally Sensitive Areas Map? CA FILE NO. Q3 -2-71 STREET FiLk Critical Areas Checklist Site Information (soils/topography/hydrology/vegetation) 1. Site Address/Location: A9 3,3— 9_7'6 Socolli Zf—Ym o/7(YY 2. Property Tax Account Number: 3. Approximate Site Size (acres or square feet): 4. Is this site currently developed? X_yes; no. If yes; how is site developed? //O 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: No ; Approx. Depth: 7. Site contains areas of seasonal standing water: Approx. Depth: What season(s) of the year? 8. Site is in the floodwayAld floodplain_ of a water course. 9. Site contains a creek or an area where water flows across the grounds surface? Flows are year- round? A/a 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: _------------------ - ----.. For.City;Staf Use Only-------- ..--- ...... 1. Site is Zoned? — 2. ' SCS mapped soil type(s)? 3. Wetland inventory or C.A. map indicates wetland present on site? _ _O 4. Critical Areas inventory or C.A. map indicates Critical Area on site? S. Site within designated earth subsidence landslide hazard area? 6. Site designated on the Environmentally Sensitive Areas Map? DETERMINATION STUDY REQUIRED WAIV Reviewed by: Planner CONDITIONAL WAIVER Y� Dat Rev OW20/93 a90.19y_ City of Edmonds 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. With a signed copy of this form, the applicant should also submit a vicinity map or plot plan for individual lots of the parcel with enough detail that City staff can find and identify the subject parcel(s). 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 Area Checklist and attest that the answers provided are factual, to the best of my knowledge (fill out the appropriate column below). Owner / Applicant: Name logs - 9" SS�ufh Street Address als 776 -A7�12 City, State, ZIP Phone Signature Date Applicant Representative: Name Street Address City, State, ZIP . Phone Signature Date 87 T11? E F; f F L 6 C I T Y O F E D M 0 N D S SEWER DEPARTMENT STOPPAGE OF SANITARY SEWER MAIN REPORT DATE: `/ani• 2- / 4/O.OD a� 7Z TIME CALL RECEIVED: F/,o�.Po,Y. . f ��r 4 LOCATION OF STOPPAGE,. E7 A1EE�t/ J%OE- YGV���: �� �iPoP�.��-�r � IX: TIME OF ARRIVAL ON THE JOB SITE: 0,X /0 /fS .F'. TIME NORMAL FLOW OF SANITARY SEWER REESTABLISHED: CAUSE OF STOPPAGE: D 7,eE 7; ACTION REQUIRED TO CLEAR MAIN AND/OR ATERAL: C:o�isrpvc7 -io.✓ �E.�L He ED ONE SEc To ✓ Of Ti G , L E le — CITY CREW ON STOPPAGE CALL OUT (Personnel Involved): >•p ' �i , LF LOCATION OF RESIDENCE AFFECTED: NAME ADDRESS AND PHONE NUMBER OF PROPERTY OWNER: � � TEiP %✓EL SOS/' •�'� 4 /0.3 3 - 9TX Sa 0, 77Y-79D DESCRIBE DAMAGE TO PRIVATE PROPERTY: L7,9SE/�E.vT.NE�P i✓aT 67ovC�.e.dEopw REMARKS: , 9/22/70 (?'R'1!IDP��f��i�f1rIC,R�/'�!!!1!1'T19.�IFNw•f'nl,.,..«•'t"Tn ..rt.u«r -.�. Twu, .—:.Iz,.e,.., t. .,n«.,. •...... ,. .. ... .«.«... .. r `f .♦ .1.;�� PAY Pt N' Qi JOB WORK ORDEi- ._,.-•-,;.J.y DATE JOB NAME SEND BILL TO g JOB LOCATION ADDRESS CITY �J CITY -- —' P ONFT C — APT. DAY WORK CONTRACT EXTP DESCRIPTION OF WORK: STARTING GATE DAY OF WEEK 0 A•w �Q . _ MECHANIC HELPER TOTAL MATERIALS TOTAL LABOR' O TOTAL AMOUNT DUE FOR ABOVE WORK: OR '7XA BILLING TO BE MAILED AFTER COMPLETION OF WORK—� S I • ••�•�..� •••.•.uvw�oago rnD sail :racrory - Completion of the above -des crlbad work: _ -d CUSTOMER'S SIGNATURE Lj NO ONE HOME .; MRK ORD.:RED BY DATE COMPLETED OR96'R TAKEN BY s - - RECEIVED PAYMENT BYI .. ±tf UTiLITY SO-010-DUPLICATE a U71LI•rY 00-020-TRIPLIC -n1 H DATE RECEIVED [PERMIT EXPIRES CITY OF EDMONDS USE - ZONE PERMIT 1 NUMBER p`!�Q0� CONSTRUCTION PERMIT APPLICATION JO8 SUITE APTM ADDRESS (��`7 •� h OWNER %&WE%AME OF BUSINESS PLAT NAME/SUBDIVISION NO. LOT NO. LID NO. LID FEE S AAL F M WAI MAILING ADDRESS(/ 3 /O _ �� _ J PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP p„, pRequired 0 O O _ V T-4 EXISTING PROPOSED StreN Use Pefrna Rp'tl O I"ap'Oor Required CITY ZIP TELEPHONE .&. Sltleealt Required O D� `/n _J't REQUIRED DEDICATION FT C/ O 7 Ww�g npuueea O NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED YES Cl NO (7 Z W ADDRESS REMARKS Z OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTRO'_IDRAINAGE 0 z W "b'dot — CITY ZIP TELEPHONE NA _ \\A ENGINEERING RE`.ltAED' T"E ADOREESS O O U FIREREVIEWED BY DATE W Cfrt ZIP TELEPHONE Z 0 LL U VARIANCE OR CU SHORELINE OR ADS* INS?ECTIoON BOND STATE LaCENSE NUMBER EXPIRATION DATE. CHECKED BY REO'D POSTED Q' -zS Gaft SEPA REVIEW COMPLETE EXEMPT SIGN AREA ALLOWED PROPOSED mEIGHT t!e._11 ?ROPOSED J a PROPERTY TAX ACCOUNT PARCEL NO. W J ✓a ^7 d 9 EXP I Vol' S 7 ❑ NEW 19 RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE ALLOWED PROPOSED REQUIRED SETBACKS (FT.) FRONT SIDE REAR ?R•Cr�Qgcp SETBACKS (FT.) F?CINt L.'? SIDE REACOMPLIANCE ❑ ALiDiTICN ❑ COMMERCIAL ❑ ORR 35f. Z0 i2 2 S - T S . � 6' 97 � �� (U si4 ' 30 ' 0 Z CHANGE OF USE PARKING REO'D PROVIDED LOT AREA PLANNV G RE`.Nc.'._O E ' OATS ❑ RcM3CEL ❑ APARTMENT ❑ SIGN a IQ ❑ RE?AJR ❑ GRADING CYDS ❑ FENCE X FT) IL r REMARKS ❑ GcMOLE r ❑ TANK ❑ OTHER , Z IQ IRA" ❑ RETAINING WALL ❑ RENEWAL �lROCKERY o F- tTYPE OF USE. BUSINESS OR ACTIVITY) EXPLAIN: CHECKED BY .. TYPE OF CONSTRUCTION C - OCr_U`?',1.•.'T a I � U GwCU,= NUI.fBER NUMBER OF CRITICAL w SPECIAL INSPECTOR' AREA JA O OF DWELLING AREAS 13) 0 STOPLES UNITS NUMBER REQUIREDQ'YES C"D pFv"n.r- wRvw rn tac nnuc ^ REMARKS. ��/y�,� PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D o m M ^ VALUATION' • „_ PLAN CHE,GK FEE HEAT SOURCE GLAZING % LOT SL PE % 0 BUILDING NL PLAN CHECK NO: VESTED DATE PLUMBING MECHANICAL THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE GRADING/FILL SEPARATE PERMISSION. � i STATE SURCHARGE 5J W PERMIT APPLICATION: 180 DAYS u PERMIT LIMIT: 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS ENG. REVIEW FEES SEE BACK OF PINK PERMIT FOR MORE INFORMATION a w 'APPLICANT ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS ENG. INSPECTION FEE W IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF i EDMONDS. WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND tANDSCP(PfIQB INSPE�fON?E / ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY = FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE PLAN CHECK DEPOSI ' R_C_I r co a DEEM E D TO MODI FY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE s NOR U`HT IN ANYWAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION." REC rI TOTAL AMOUNT DUE I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION GIVEN IS CORRECT. AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF APPLICATION APPROVAL THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- TION: AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FwJ4'e^y Cry,_ 4: T .,x C,n' :.ptry;pQ•, LtrL,CVftlaR.:pYG.. JGC IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27. _ e SIGNATUR (OWNE R AGENT DATE SIGNED] (425) J 1-0220 ATTENTION EXT1333 IT IS UNLA.VFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221 A FINAL It-SPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- CATE OF CCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FAX - S/98 160A RECEIVED CLAIM FOR DAMAGES } �1 FEB 7 i972 NOTICE U �r,�, U FILE Claim MUST be filed with City Clerk and presented to the City Council within 120 days from the date that the damage occurred or the injury was sustained. TO THE CITY COUNCIL OF THE CITY OF EDMONDS: PLEASE TAKE: NOTICE, THAT !f//I/TF/i 1Z-�.7�an,F;1r LL-7 -,v.CLAIMANT9 (if married, give both wife'and husband's name) WHO NOW RESIDES AT le .3 3 -- q E22 fl d Ste, �`�/`i e.��DS lNn.,? (State present actual address by street, number & city) AND WHO FOR SIX MONTHS LAST PAST HAS RESIDED AT Give residence by street, number and city CLAIMS DAMAGES OF AND FROM THE CITY OF EDMONDS IN THE SUM OF $ C�l arising out of the following circumstances: Describe defect, giving on nct�. ];;8_ 5us-n_i Qi of e l sei,�P-r wns'roken DATE and TIME injury or while installing a skprm drain. Bob T,Iay damage occurred, PLACE and; 11tili-rJes, form. ,n4iyPts notified-, I and full particulars. was advised ;,o ivait and see. pn Dec. 16 Accurately locate and 59 days later the sever became plugged. . describe defects caus- pn Dec- 17 plum-ber ran rooter ouz to the ing injury or damage exact spot su�ri ci one , Pale -natFr r n and and all acts of negli- Al were also here. Drain se'ei:ieu open, Bence claimed. so it viLjs decided to vjait and. sepl. *f: it plugged again. It did 'on Jan. 23 and las repaired on Tan 2ZL . Agin r,Tay insnFctea. Accurately describe injuries or damage. State items of damage claimed. Itemize all expenses and losses Broken seder nair ami miF_lt Plunoinw bi 11 erlr'► osed for A68.51 r. (Claim must be sworn to by claimant) Signature of Claimant SUBSCRIBED and SWORN TO before me this /,r/ day of_-, %� , l9 % _';I - Notary :Public in and for jhe State. of Washington, residing E�'E� �WE ' Q I E E-a ' 7.1972 CITY P 0F E06MONOS ciry, ci.EP,k;