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1109 BST�E
ADDRESS: 0 U I —,A— Aw-,nu-e,
TAX ACCOUNT/PARCEL NUMBER: _()b(D 17 "t D I D bI D O A
BUILDING PERMIT (NEW STRUCTURE):
COVENANTS(RECORDED)FOR:
CRITICAL AREAS A/ DETERMINATION: ❑ Conditional Waiver ❑ Study Required ❑ Waiver
DISCRETIONARY PERMIT #'S:
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED
PERMITS (OTHER):
PLANNING DATA CHECKLIST DA
SCALED PLOT PLAN DATED:
SEWER LID FEE $:
SHORT PLAT FILE:
SIDE SEWER AS BUILT DATED;
SIDE SEWER PERMIT(S) #:
GEOTECH REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
WATER METER TAP CARD DATED:
OTHER:
LID #:
LOT: BLOCK:
L:\TEMP\DST's\Forms\Street File Checklist.doc
APPLICATION
for
The City of Edmonds SIDE SEWER PERMIT EASEMENT No ..............................
NEW CONSTRUCTION REPAIRS
107-03900
OWNER...."...................................................... CONTRACTOR."""""""""""""""""""..................................................." "" PERMIT No.......................
ADDRESS .....---S"t4V8t.......................................... ................... LEGAL DESCRIPTION: LOT No............................................... BLOCK No. ...................................
NAMEOF ADDITION.................................."---......"........."............"•"•"-"""-•--"........................................................
0
DYE TESTED ON SEWER
JULY, 1972
Approved:
DATE................. BY.....................................................................