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CITY 04
FILE
RECEIVED
SIDE SEWER. PERMIT
For Inspection a 771-3202
NOVA 6 1984
PERMIT NO.47226
PUBLIC N10RK� L�Y.NIVWOOD..l.INE
Address of Construction: ` 117�
y .
Property Legal Description (Incl.ude all
easements):.
161
3/
Owner and/or Builder: �3 o \_'� ri V 6_ r,'
Contractor & License No: V'e_ 4)- C
Single Family Residence
Multi -Family (No. of Units )
Commercial (No. of fixture Units )
-k- Cov^p0-"'c.A�01A
Invasion into City Right -of -Way: No �_ Yes (If Yes, Right -of -Way
Construction Permit required. Call One -Call -Center (1-800-424-5555) before any
excavation.)
Cross other Private Property: No Yes (If Yes, easement required,
attach legal description and county easement number.)
PLEASE READ THE ITEMS LISTED ON THE BACK
I certify that I have read.and shall comply
with the items listed on the back.
Permit Fee:
Tr.'unk Charge: Zs�
Assessment Fee:
Issued By:
Date Issued:
Receipt No.. 1(04t
1Q6J, 1(' I \ �, t
Date
Partial Inspection:
Comments Date Initial
Final Inspection Approved:
Date Ini . 1
°�° Rejected:
CD
Reason Date Initial
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** PERMIT MUST BE POSTED ON JOB SITE **
a�
ce- Wh-ite Copy - File Green Copy - Inspector Buff Copy - Applicant
TMeide Sewer Drawing
The City of Edmonds S"�`r"} NO_ --------
NEW CONSTRUCTION ❑ REPAIRS E] LID NO . .................. . ASIA r, v
OWNER --- BOR? ---- Rv ----------------------------------------------------- CONTRACTOR - ----- Pe- J� ... ------------------------- PERMIT NO. -0.772-Ma.
JOB ADDRESS ----- LrJ114 ------------- (6-0a -------------------------------------------- LEGAL DESCRIPTION: LOT NO. ----- ------------------------- BLOCK NO. ------ Z-1 ---------------- --------
----------------------------- ...... ---- --------
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PWW-0001 -11/75 (REV. 11/78)
Approved:
-------------
--- 2-0. li 3 -------------- BY ---- --- /4/
DATE -----
CITY OF E,DMONDS STREET SECTION
STRE" CUT REPAIR
EFUTILITY ORSR/WECONSTRUCTION WORK ORDER
ADDRESS OF PROPERTY
INVOLVED: j c:Z�, I y 6 (,y . DATE RECEIVED: BY: t
NAME: HO T4 , RECEIPT NO.: i Z'- y
MAILING ADDRESS: 12y ZZ P,", in,-\ n
l'Acv-,n,-\h S 9 c2o
BUILDING PERMIT NO.:
SIDE SEWER PERMIT NO.:
R/W CONSTRUCTION PERMIT NO.y
WATER METER PROJECT NO.:
STREET CUT DEPOSIT:
-----------------------------------------------------------------------------------
TYPE OF REPAIR: ASPHALT ROADWAY CONCRETE SIDEWALK CONCRETE CURB
WATER METER CUT UTILITIES CUT
TOTAL AREA REPAIRED _:�L FT. x -30 FT., TOTAL SQUARE YDS./LN. FT. G�C,i %
Sq. Yds./Ln. Ft. Minimum Charges @ $—iL O4 = $ -),a Op
Sq. Yds./Ln. Ft. Additional @ $ $ 3_s , a3
=1
=j
TOTAL COST ................ _ $ I , C 3
FUND #620 DEPOSIT FEE. ............................................ _ $Z „ Z-a a—
TOTAL REIMBURSEMENT .............................................. _ $ J 3•!
TOTAL ADDITIONAL EXPENSE TO BILL ................................. _ $
STREET CUT REPAIR REQUIRED: YES_ NO
THE FINANCE DIVISION IS AUTHORIZED TO:
/xC PREPARE A CHECK IN THE AMOUNT OF $ �73, / MADE PAYABLE TO THE ABOVE
BILL THE ABOVE MENTIONED COMPANY FOR $ ,,TO COVER ADDITIONAL
EXPENSE I R D BY TX ST EET DIVISION ON THE ABOVE//S-GBJECT WORK
REQUESTED BY: ` 3(� APPROVED BY:
cET SUPERVISOR DATE SUPT. P.W. DATE
VERIFIED BY:
WORK ORDER COORDINATOR DATE J U L 2 b WU
R/W/FORMS �.� -. PUBLIC
CITY OF EDMONDS
COMMUNITY SERVICES DEPARTMENT
'RI614I'-OF-WAY CONSTRUCTION PERMIT
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A. • Owner: r-J.
Mailing Address_
B. • Contractor:
Permit No.
Issue Date /9
Name
Mailing Address
City "'State Zip City State Zip
State License Number Telephone Number'
C. • Address or Vicinity of Construction:
Type of Work to be Done: 1 6 �� l' - V= �� _ ` ` (!' Ili !
1 f / .� i`, � � ✓"'t,- r 1� ! ii�; I �`�...�_. �_� -!"1 ' ..ii='�_ s`1
- i
D. • Work in Connection With: i -§u- b or Plat ❑ Single Family
❑ Commercial ❑ Multifamily t
E. • Pavement Cut: 1 Y J❑ N F. • Size of Cut: L 1 X
❑ City Projects
❑ Utility
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 material prior to end of working day;
NO EXCEPTIONS.
understand the above and that this permit must be available at the job site for inspection purposes at all times.
Signature: _ t "' Date:
Owner `or Contractor J
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 �"O days
Special Conditions:
PERMIT FEE:
30
Restoration Fee:
Receipt No.: �/Z ?�_14
Fund 111 Fee: n___
-
Street Cut Dimensions:
RELEASED BY: J-2 6 Dat l� INSPECTED BY Date
NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE
Enc. Div. March 19.N9
OV.2" -4;
..............
W,
U
City'of Edmonds
14
Community Services
Date: -712
klofro
Received of: IT.
Check lZI, Cash
Water Meter
Water Connection
Street Cut
Sewer Permit/Repair
Trunk Charge
Sewer Connection
Fence Permit
R/W Invasion 4?0— 34 8
Street Restoration Deposit (620 fund)
Street Use Permit
Building Permit: (Type)
Plan Check/Plat Inspection
Specs & Plans Deposit
Zoning Applications
Shoreline Permits
S.E.P.A. Review
Recording Fee
Maps/Books
Photostating
State Surcharge
Energy Code Fee
Permit #
Date of Hearing: Time:
By: