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CATHODIC PROTECTION PRIORITY WOK
T R E ET FILE City of Edmonds
RIGHT-OF-WAY CONSTRUCTION
�.
PERMIT Peat Number. - -�
P Issue Date:
A. Address or Vicinity of Cdhstruction: 1240 8 AV S
18 --wanow— C B. Type of Work (be specific): INSTALL TEST LEAD WIRES ON 1/2
9 0 - 19
STUB AT 197' N CL OF BIRCH ST AND 141 W CL
C. Contractor: WACHTNTON NATUr. RAT. AR Contact: CONNTF. CARRON 8 AV S
r.
Mailing Address: R15 MF.RCF.R ST Phone: 521 5264
State License #: Liability Insurance: Bond: $
D. Building Permit # (if applicable): Side Sewer Permit # (if applicable):
E. ❑ Commercial ❑ Subdivision ❑ City Project ❑ Utility (PUD, GTE, WNG, CABLE, WATER)
❑ Multi -Family ❑ Single Family ❑ Other
INSPECTOR: INSPECTOR: i 7 CA, tT
F. Pavement or Concrete Cut : ❑ Yes ®No G. Size of Cut: x H. Charge $
APPLICANT TO READ AND S '
INDEMNITY. Applicant understands and by his signature to this application, agrees to h d t City of Edmonds harmless from injuries, damages, or
claims of any kind or description whatsoever, foreseen or unforeseen, that maybe mad a�gai t the Cityaof Edmonds, or any of its departments or
employees, including or not limited to the defense of any legal proceedings including defense, cost and SFttorney fees by reason of granting this permit.
THE CONTRACTOR IS RESPONSIBLE,-FOR'WOIi MANSHIP 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 P�QCE, SED 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 alor ins ec ion. purposes.
Signature: / Date:
(Contractor or Agent)
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY: (.L,1, 1444,1V RIGHT OF WAY DEPOSIT
TIME AUTHORIZED: VOID AFTER % �1E�fi' DAYS, DISRUPTION FEE/FUND Ill:''
SPECIAL CONDITIONS: G 4T S RESTORATION FEE:
COMMENTS:
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
En1,rrg. I)iv. 1991
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 ❑ NO
Date:
Date:
C . M
M
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Naknil
AVAeVVICnEnemyGo rMV
Addendum to :
Submitted
iz4o
IR`i ►a
B�ec-H
WNG to window I Z w(Z- a AV S
Q/A Water main depth
unknown
111L 11 gas main
0
ROUTE & FILE
City of Edmonds
Right of Way
Permit Application
Connie Carbon
Field Representative
Washington Natural Gas
521-5264
15-�4kr
,L -z is A v 1 fl G. .�
Key:
4w- water
-g- gas
-ss- sewer
-0- water hydrant
0 water valve
WNG 929.1 s (12/83)
/980 /962 M I /q7q S s/8+
w
N e" ma's 2az - a , 9 g'.
/98/ /41Y • J � 8
1"o /44w-425'S 2�
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Q sc• 3 m
m
►79n1 19i)0
4- swiasw
'w 1991cm 177 1"15N /959
v
A4'N N RI
1972 v F PE �}
lo'w-45'!N (BIRCH" RD) "
ROPED �
-.5ory ST 223
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ADDRESS
CITY
am S
PLAT NO.
OP NO.
JOB NO.
LOCATE NO.
PRESSURE
LP I HP
CONTACT NAME
PHONE NO.
INITIATED BY (FULL NAME)
DATE INITIATED
DATE WANTED
EXISTINCy STUB ❑ SERVICE
T
STw ❑ BARE STEE ❑ Cl ❑ WI ❑ PE
SIZE '
LOCATION
IF 73 l ck (,
EXISTING MAIN
❑ STW ❑ BARE STEEL ❑ Cl ❑ WI ❑ PE
SIZE
LOCATION
INSTRUCTIONS:
1
WORK COMPLETED:
�( dCIS
DATE COMPLETE:
CATHODIC PROTECTION TEST STATION
COR/CON NO.
NEW PIPE FOOTAGE
❑ MAIN ❑ SERVICE
TEST SITE 1 1 6 2 7 3 8 4 9 5 0
PSP
TYPE OF PIPE
TEST SITE
LOCATION:
FITTER: ST O.T.' HELPER: ST. O.T.
JOB REPORT [D-1 ] WNG 563.13 S (9/92)
w
STREET RLE
BUILDING Pl:i';IT PT.VP'-'
Street Pliplit-of-l:aN Existing
Access rase acnts rxisting Q n.� Rl:nD
Utility Fascrnent Rxisting ILr:Gh ,
Lot Pcr Sl;aciivisi.on Plat ...... !Assessor t'an
1
Sit., Pliul r7:ec.:cc1 for ,lceuracv
1
I'll dcrgrou,ld--
Cd;�;,r (lc�'1tr::u 1i'�c�al �•_���, f�itJR r�
� 1
ll;.'c':rant l,c(uired pcy hre
E `� Dctc•r_-tor ('!!cc'.•i ,:ctcr 1.c(:�li�- _.
'. f,i"r�i141"c'(1
Septic Tani. 1k::;j,;;: ?,ppl-o ed _
Schti.c ..:1:,=11,1i.t Rc(r,li.rccl __--
Suni.tnn• Se;:cr Avni.lai:%
Side sel•.cr
S�1a�,-y Sc:-cr Connection Fcc F'c:nui.red
l:c;vic:� l��•
Culvert Pc-cuircd
i. ze
hate
Si.
Date
ro i
Catch Ml!r i rl Pu(itti reel _ _ <1i.C1t C on ` i *c M nn
l�n tt� at�n c
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Nall"lolc ;(i
c(luoi. ntior,� Groluld later I i.cicl (11ccLcd
Indicate or Site
R1tC.—___�_-�_R'rry nr rri,NA
tF", C�
Strect-l-avin , RR-ccluircd
(:u
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Sidcr: IIL- Pcntli.rcd -�•.
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n.irb Out for Privc,,av Required
I%i- lit -of -1,ay Construction Pc Required
Boncl Rccluirccl fo )lic Improvements
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Strcct " tc Si.Sn RIcritirc(1
Othcr 'Sinirg l)couircd
I�
Pre ncCtion maclo On
_
Scwcr
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Strcct_`
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S;)ecil ?'cct;i.rc :eats 1 i ,ted in Inemo to, Pui l.c':in}h:}
ru tr cl:t
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in on LLil(jin}; I'cr,nit ,1}»)li.ca;:10n
I);itc 22
St":un )cd ,^;l(. i OtaticnIs . f;1(lC
71
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fkj-")rcvccl b)' PLIi)11 C I:O7'J.S hC',}) 1rLI1CIlt
APPLICATION
L' ,. for
The Cityof Edmo L SIDE SEWER PERNIIT
"S ��� ;�
EASEMENT No . ..........................................
NEW CONSTRUCTION ❑ REPAIRS ❑
400-08600
OWNER........... R � M.e..- P f t.I�gl"�5�............................................................. CONTRACTOR....-•--••--•-------........................................-----...............................-- PERMIT No.......................
ADDRESS .......12!40 8th Avenue s .... BLOCK
............... LEGAL DESCRIPTION: LOT No..------•-------•---............•---•---•-••... No. ............................................
•-------------------•--
eNAME OF ADDITION............................................••---....----......-----.....................................................................
i
•
Dye Tested On Sewer 1972
Approved:
DATE................................................ By.....................................-----............................
APPLICATION EDMONDS
S ;SET FILE Ii TRH, fOENT PLAN
for
TW City of Edmonds
SIDE SEWER PERMIT EASEMENT No...
NEW CONSTRUCTION ❑ REPAIRS [ ..
OWNER ..... ...:,/....-`..................................... �.�
CONTRACTOR ....= -.................. PERMIT No.......�.
ADDRESS .:..........cam 1.-. ..........:...--......... �`.................. LEGAL DESCRIPTION: LOT No................... ............................ BLOCK No, .................... .........-..........
NAMEOF ADDYTION ....................................................................................... ...........„..
Approved:
DATE.......1.- ....:... ......... ..1..... By ......`� ..�::............ ..... ..........................