17110 67TH AVE W.PDF17110 67TH AVE W
APPLICATION
for
S11DE SEWER PERMIT
he City of Edmonds
EASEMENT No . ..........................................
NEW CONSTRUCTION REPAIRS 0
JIKA NLLF�-N -T*
OVVNER ........................................................................................................ ... gfg-02*4 .... .....
......... CONTRACTORE!�'�.. ....... ( ------ PERMT No.
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ADDRESS..........................................................................................................
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LEGAL DESCRIPTION: LOT No...: .............. I ... z ......................... BLOCK No . ..........................................
NAME OF ADDITION ... D .... e�L-V= . ......... Pl.r> ........... V-tho"'< .....................................
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DAT< .11- IZ
ow-10.0 ...............
No
APPLICATION
for
The City of Edmonds SEDE SEWER PERNaT EASEMENT No . ..........................
NEW CONSTRUCTION ?r— REPAIRS 0 c--/—Z)
OWNER ....... -- - ------ ............................................. CONTRACTOR -Is 0
........... _V
.................. PERMIT No.
ADDRESS ............ 4.1w — ------ ....... LEGAL DESCRIPTION: LOT No . .......... ........................ BLoOCK N .. ............................................
NAME OF ADDITION ...... /. & ..... ...... /V�'.On . "e,
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DATE................................................ By ......................................................................
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5239
1711-0 67TH AVE W
-.1. 16,
City of Edmonds
Development Services Department
Planning Division
Phone: ,425,771.0220
Fax: 425.771.0221
DATED RECEIVED:
CITY RECEIPT#: 7 �/ 71f
Critical Areas File#: 02-1001 —O(D.63
Critical Areas Checklist Feei t46.00
,.DATE MAILED TOAPPLI CANT: -0 /-07
CRITICAL AREAS CHECKLIST
The Critical Areas Checklist contained on this form is
to be filled out by any person preparing a Development
Permit Application for the City of Edmonds prior -to
his/her submittal of a development permit to the City. - -
The purpose of the Checklist is to enable City -staff to
determine whether any potential Critical Areas are, or
may be, present on the subject property. The
information needed to complete the Checklist should
be ' easily available from observations of the site or data
available at City Hall (Critical areas inventories, maps,
or soil surveys).
An applicant, or his/or representative, must fill out th e,
checklist, sign and date it, and submit it to the City.
The City will review the checklist, make a precursory
site visit, and make a determination of the subsequent
Steps 'necessary to com plete a development permit
application.
Please submit a vicinity map, along with the signed
copy of this form - to assist City staff in finding and
locating the specific piece of property described on this
form. In addition, the applicant shall include other
pertinent information (e.g. site plan, topography map,
etc.) or studies in conjunction with this Checklist to
assistant staff in completing their preliminary
assessment of the site.
I have completed the attached CRITICAL AREAS CHECKLIST and attest ihat the answers provided are
factual to the best of my knowledge (fill out the appropriate column below).
PLEASE PRINT CLEARLY
Owner/Applicant:
'Jam �kk�Lkwv5 -Dw
Name
Ono V7 4�h
Street Address
M0 V� 18 6. �40
City State .,Zip
Telephone:
Signature Date:
Applicant Representative:
Name
Street Address
City State Zip
Telephone:
Signature
Date:
G:\Share\Librwy\Planning\Fonns\Public Handouts\ Critical Areas Checklist Doc/1-16-2001
Critical Are , as Checklist CA File No:
Site Information (sofls/ topography/ hydrology/ vegetation)
1. Site Address/ Location: 17110 e - W
2. Property Tax Account Number: 414 -7 - 000 - oi7� oo
3. Approxuinate Site Size (acres or square feet):
4. Is this site currently developed? Vyes; no.
If yes; how is site developed? _hou5s-
5. Describe the general site topography. (Zheck all that apply.
X Flat: less than 5-feet elevation change over entire site.
Rolling: slopes on site generally less than 15% (a vertical rise of 10-feet over a horizontal
distance of 66-feet).
Hilly: slopes present. on site of more than 15% and less than 30% a vertical rise of 10-feet
over a horizontal distance of M to 66-feet).
Steep: grades of greater than 30% present on site (a vertical rise of 10-feet over a horizontal
distance of less than'33-f6et).
Other (please describe):
6. Site contains areas of year-round standing water: Approx. Depth:
7. Site contains areas of seasonal standing water: Approx. Depth:
What season(s) of the year7
8. Site is in the floodway floodplain Ale of a water course.
9. Site contains a creek or an area where water flows across the grounds surface? Flows are year-round?
'A/0 Flows are seasonal? - (What time of year?
10. Site is primarily: forested meadow ;shrubs mixed
urban landscaped (lawnshrubs etc)
11. Obvious wetland is present on site:
G:\Sharc\Library\Planning\Forms\Public Handouts\ Critical Areas Checklist Doc/1-16-2001