10526 231ST ST SW.PDF10526 231 ST ST SW
MS26-
TAX ACCOUNT/PARCEL NUMBER
0
2
BUILDING PERMIT (NEW STRUCTURE):
COVENANTS (RECORDED) FOR:
3 1 (st
- �2-6/
U
I - 00
CRITICAL AREAS: DETERMINATION: ❑ Conditional Waiver ❑ Study Required [j Waiver
DISCRETIONARY PERMIT
DRAINAGE PLAN DA
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED
PERMITS (OTHER):
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DA
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 METER TAP CARD DATED:
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t City of Edmon
�JMHT-OF-WAY CONSTRUCTION
VIC
�Qwit PERMIT Permit Number. 97 07 9
Issue Date 9
G� hh
A. Address or Vicinity of Construction: ( s"o
J 8 9B. Type of Work (be specific): c,(
p-19
C. Contractor: Pa— I
Mailing Address:
State License tt:
D. Building Permit # (if applicable):
r
Contact:
Phone:
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 , 1 G. Size of Cut:, . x H. Charge $
APPLICANT TO REAVAND SIGN
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 costa, 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
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 site at all times for inspection purposes.
Signature:
(Contractor or Agent)
Date:
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY: G.. RIGHT OF. WAY DEPOSIT
100
TIME AUTHORIZED: VOID AFTER —!—C ` DAYS- DISRUPTION FEE/FUND Ill:
SPECIAL CONDITIONS:
COMMENTS:
DATE:
RESTORATION FEE: I
PERMIT FEE:
TOTAL FEE:
RECEIPT FEE:
ISSUED BY:
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Eng. Div. 1994
•
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