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1120 SIERRA PL
0
ADDRESS:! l 62U
TAX ACCOUNT/PARCEL NUMBER:
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):
SCALED PLOT PLAN DATED:
SEWER LID FEE $: LID #:
SHORT PLAT FILE: LOT: BLOCK:
SIDE SEWER AS BUILT DATED: Z-,23-63
SIDE SEWER PERMIT(S) #:
GEOTECH REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
WATER METE11 TAP CARD DATED:
L:\TEMP\DSTs\Forms\Street File Checklist.doc
APPLICATION CARD No . ..........................................
for
The City of Edmonds SIDE SEWER PERMIT EASEMENT No . ............................................
OUTSIDE ❑ INSIDE ❑ REPAIRS 0
/8 6z 0
OWNER ......... .......... CONTRACTOR .... .,, ..�t �»y...... ................................ PERMIT No.. �'.!.., .
STREET 7
HOUSE No......................0.......5..!.G.�'..K............I......1.a ce............................*.. AVENUE LOT No....�.1 aZ..i%LOCK No............................................................
NAMEADD...�...................................................................................................................................................................
\40
M
Date Approved:
BACKFILL WORK ORDER ISSUED ............................................ DEPOSIT, $ ...................................................... ,,�
SEWER WORK ORDER ISSUED ................................................ DATE.. ,� .... BY .../,1. IYf,...... ...............)....................................
APPLICATION
for
The City of Edmonds SIDE SEWER PERMT
EASEMENT No...........................................
NEW CONSTRUCTION ❑ REPAIRS ❑
118-06100
OWNER.......... Am...Pt... $eVQr an.............................................................. CONTRACTOR...............................-•---..........--•--•--••-•--•--•--...............---.............. PERMIT No.......................
ADDRESS 1120 Sierra Place
..................................... LEGAL DESCRIPTION: LOT No. .............................................. BLOCK No.
1
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NAMEOF ADDITION....-----•--•............................................................................................................................
Dye Tested On Sewer 1972
Approved:
DATE................................................ BY••----................................................................
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CLTY OF EDMONDS
COMMUNITY SERVICES DEPARTMENT
RIGHT-OF-WAY CONSTRUCTION PERMIT
Permit No. (� 1 _�3
Issue Date
A. • Owner: �� �</"JB''' B. • Contractor: elm,i< (<ifl�l/�° <-fir �l�r/A
Name me_.-••--
\ e
Mail' Addre Mail ng A do r
!or 6r <il/l�( - a 1 ?_ \ -
City State Zip City Sta e Zi
7� State Ltcense Number Telephone Number
C. • Address or Vicinity of Construction: AV c `rst'�� 4 W ' - _
Type of Work to be Done:
D. • Work in Connection With: ❑ Sub or Plat Single Family ❑ City Projects
❑ Commercial El Multifamily ❑ Utility
E. • Pavement Cut: El AN F. • Size of Cut: X
APPLICANT TO READ AND SIGN
INDEMNITY: 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, forseen or unforseen, 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, court 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 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.
• A 24 hour notice is required for inspection; Please call Engineering: 771-3202
• Work is to be inspected during progress and at completion.
• Restoration to be in accordance with City Code.
• Street to be kept clean at all times.
• Traffic Control to be in accordance with City regulations.
• All street -cut ditches must be patched with asphalt or City approved materiaglo w king day;
�
NO EXCEPTIONS. FILE
understand the above and that this permit must be available at the job site for inspection purposes at all times.
Signature: Date: CXI -- p�
O ner or Contractor
This Permit Must be Posted at the Job Site For Inspection Purposes
Call DIAL -A -DIG Prior to Beginning Work
APPROVED BY:
Time Authorized: Void after days.
r
Special Conditions- 04 �' =d '
RELEASED BY:
Date
PERMIT FEE: 30- 00
Restoration Fee:
Receipt No.:
Fund III Fee:
Street Cut Dimensions:
INSPECTED BY
NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE
Date
Eng. Div. March 1999
Eng. Div. July 1985
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