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1111 BROOKMERE DR.PDFiiiiiiiiiiiiii 10451 1111 BROOKMERE DR ADDRESS: TAX ACCOUNT/PARCEL NUMBER: O D �Jq �� D D 02W BUILDING PERMIT (NEW STRUCTURE): COVENANTS(RECORDED)FOR: CRITICAL AREAS: DETERMINATION: ❑ Conditional Waiver ❑ Study Required ❑ Waiver DISCRETIONARY PERMIT #'S: DRAINAGE PLAN DATED: PARKING AGREEMENTS DATED: EASEMENT(S) RECORDED FOR: PERMITS (OTHER): �d I d o� I tS� I l 11 �1 1 �I % � ?Zl - �I4S) 4�1a, PLANNING DATA CHECKLIST DA' SCALED PLOT PLAN DA' SEWER LID FEE $: LID #: qI SHORT PLAT FILE: 't LOT:69 BLOCK: SIDE SEWER AS BUILT DATED: J+1-L5) p A SIDE SEWER PERMIT(S) #: GEOTECH REPORT DATED: STREET USE / ENCROACHMENT PERMIT #: FOR: 1 I\ WATER METER TAP CARD DATED: OTHERS2Q LATEMP\DSTs\romis\Street File Checklist.doc CITY OF EDMONDS "- Pe,nWo. PUBLIC WORKS DEPARTMENT STREET FILE Issue Date`- RIGHT - OF - WAY CONSTRUCTION PERMIT' _ 1 A. *Address or vicinity of Construction 1111 Rrooleme-A T1r Plat A 197-066 • Owner: Washington Natural Gas Name 80S 1 56 AV NE Mailing Address >BBellevue. Washianton 9800 City, State, Zip Code • Contractor: Same As Above Name • 001 • Permit Issued To: Type of Work to be Done: InstaI 1 NTPy,,r Seri ce • Work in Connection With: ❑ Sub or Plat ® Single Family ❑ Comml. / Ind. ❑ Apt. Condo. • Pavement Cut: ❑ Yes ❑ No F., Mailing Address State License Number UCity, State, Zip Code Telephone Number a * * NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE B. APPLICANT TO READ AND SIGN as Q 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 aagainst 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.' O wUpon 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. O E~ . • . Funds held from the Security Deposit (estimated restoration fee) will be held untilAe final street patch is completed, at which time a debit o'r 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 Signature: .. Owner or A be available V e j ®.V for inspection purposes at all times. may. 7. 8 a 1. 9-8 l THIS PERMIT MUST BE POSTED AT THE JOB SIT FOR INSPECTION PURPOSES CALL DIAL - DIG PRIOR TO BEGINNING WORK C. Issued By: % r1F� ✓ Time Authorized: Vold after % 1 days Special Conditions: Ammendments: Permit Fee: Security Deposit: Receipt No.: Fund ill Fee: Street Cut Dimensions X = * * NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE * * Eng. Div. December 1978 FIELD INSPECT17M NOTES (Fund-111'1-' Route copy to Street Dept. rnmmPntG- Diagram: Contractor called for inspection- Yes Nork Disapproved By: Date: Work Approved By : Date: Inspector: NO Bv: Date: Ena. Div. December 1978 rL. < o o"I FT Q► c C4 sk. LIVE %N/A �w �� I'A10 JAN 21 ..................._.......District City of Edmonds ---Water Department TAP CARD ... 19.6 . ............ No................. .. ............ No ......................... Meter.5 Tap I Size- ............................ Size......::........._...............:_. Mfgr, N ........... Style ................ .... ....................... For ...................... .. V--� .................. ............................................................................ .......... . ......................... . ...... .... . . LotNo ........................................... Blk. No...................................._.............. Add. ..................................................................................................... . .................... Service Location ...................... ....................................... ................. ...................................................................................... . ........ ...... r . .............. MeterLocation ..................................................................... ................................................................................................................. . ....... . .............. MakeTap ............................................................................................................... ................................................................................ Pressure .............................. lbs. Test .................................... 70 SendBills to ...................................................................................................... .......................................................................................................... . ....... . .............. Dateof WQXk .... /-, ........ ..................................... ....... ............................... Foreman ...................... Guar. Voucher No ........................................... $ ........................................... Remarks: ......................................................... . ........................................................ ........................................................................................................................ . . .............. .................................................... .. ............ .......................................................................................... E* . ........ . .............. .................................................. ............................................................... . ...... . ........... OUTGOING. Index. -.......Reg....... Route Bk ......... Stencil ...... Card ..... — INCOMING Index....._... Reg....... Route Bk ......... Stencil ...... Card .. . ... M? - 4al Chargeable to Installation Me '-s NO. ...... T---- SIZE ........ - DESCRIPTION Meter...................................... Meter Box .............................. RATE .............. .............. AMOUNT . .... ............... ........ - Meter Plate ............................ .............. . ........... . . ....... ........... ..... Check Valve .......................... .............. . . ......... .......... . . . . . . 7 - - - - - - - - - - - - - - - - Pipe, Galv. Screw .................. .............. . . ......... .......... ............. .......... Nipples .................................... .............. . ......... .......... ........ ...... ............. .......... .......... Bushings . .................................. Plafil Ells ........ * ........... * ---- * ------ .............. ----- * .... ............ * ............ .......... ..... * .... ....................... St. Ells .................................... .............. ............ .......... .......... ... ........ Tees ............... ..... ...... ........... .......... ............ . ........ - ...... . .......... ......... i ...........- -................................... /-- . ................. - ---................. .............. ............... .............. ............. .......... .. . .............. .............. Material Chargeable to Taps Connected , NO. , SIZE DESCRIPTION RATE AMOUNT ............ .......... Pipe, Black Screw .................. ............. ............. ......... ........................ Pipe, Galv. Screw .................. .............. ............. ......... ........................ Lead Connections - ................ .............. .......... . ......... .... .... .... . ..Corp. Curb Cocks .......................................... Cocks ........................... .................... ................ .............. ...... ... Unions .............. --------------- ----- ** ....... ............. ...... .......... ... .......... Saddles ................................ ... .............. ........... . .......... .............. .......... Nipples .................................... ............... .......... . ..............I......__ Bushings ................. ................ .............. .......... Plain Ells ................................ .... . I --- * ...... .............. ............. ......... . .......... .......... Street Ells ........................... Tees .......................................... ............ ............. ..... W.* .............. .......... Curb Boxes ............................ ............. .. .......... .......... S. O. Extensions .................................. ............ .......... .............. .......... Gates ........................................ .............. ............ ........... .............. .......... Plugs ........................................ ............. ............ .......... ......................... Couplings ....... ....................... I ............. ............. .......... .............. .............. .- .......... .............. .............. ............ .......... .......... ..... .... .......... .......... .......... Gate Boxes ............................ ....................................... ........... ............... ..................................................... ........................................................... ........................................................... ..................... ..................................... .............. ............... .............. .............. .............. ............. ....................... ............ T . ......... .... . ....... ............. ........ - .......... .......... . ....... . ....... .............. ........ .............. - ........... ............... ............... ..... .... .......... . ..... I .. .......... .......... . ........ ... ......................................................... . ........................................................... ............................... ........................................................... ........................................................... ................... I ....................................... Hours Time —Day Men -------- Hours Time —Monthly Men ................ .............. ............... ......... ............... ............... ............... ----- ............. ............ * ............ ............ ............ ............ .... z . ........ . ........ .......... .......... .......... .......... ........... Hours Time —Auto ............. ... 4/ ......... ............ .......... ........ ..... ..Superintendence .............. t Total .......... 2