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17120 67TH AVE W
The City of Edmonds
APPLICATION
for
SIDE SEWER PERMIT
NEW CONSTRUCTION REPAIRS 0
EASEMENT No . ...............
................................................ . .......... -. 4 44��, 1
OWNER o-.JW!A� ---- ..... CONTRACTOR ............ PERMIT No . ......................
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ADDRESS ......... ......... LEGAL DESCRIPTION: LOT No . ................ .................... BLOCK No . ............................................
NAMEOF ADDITION ...........................................................................................
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Approved:
DATE. . ..... .. . ....
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The City of Edmonds
APPLICATION
for
SIDE SEWER PERYaT
NEW CONSTRUCTIONN�- REPAIRS 0
EASEMENT No . ..........................................
16 191 rl3;)
OV*rNER ... ........... (^c.---,!rAJ ---------------------------- CONTRACTOR AJ / i & —zjv V, &J ............. PERMIT No.
LEGAL DESCRIPTION ...... ..................... BLOCK No. Cf..
ADDRESS --- [17-/�""'.0 ........ ....... AV - ------ 4�� .................. ]�JT No. . .....
NAME OF ADDITION . ........ . ............... . . ......... �D ....... ..... .............
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Approved:
DATE................................................ By ..................................................................
AER PER
E V W V MAIT''
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�WA.T.-EW.S�F,,W)ER.,DEPAIP.,T�MEN,�T,'
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jGall� 716-1107i,for- side. sewer,-,Inspe - eti.ons; �BEFORE� �c,cyvering,'-,any,.;"portionl,z . of the, con - structiont
one
rnspecflbnV,�vill� bel tprovided',,withliar,24, Iladursrafter requea�.; -,,i40)!Sae_).Siin1_, 6ioholiday,'- ins6ecti
ON,$ OTION." 17:1 M 67t venue- wiist
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........ .............. .................................. . ........................
................................
'Lot- pcts:
4T Y4 ?)DESG RIPTTO I .......
�,,-'PRORE ...................................
........... ......
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.................................. /OIV,,AV ER ........ .................. ........................ .................... ........................................................
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................................................. .............. ......................................................
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Septdmber TO 3
........................................ 1 ....... .......... 191 .......... �for;,r'epi�ii,,,andV,6rlfconneet'on �of,w'r4de",*liewer, lo; Uei,;P,4y,�f�"�tar sewer�
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1T T.Of`I:I�E'� FOLLOWING::'
IONI �'D,",'
"No: -to,-construct"sewer Anslde.propertrlfne�z� :jicensed1,Sicfe1Se* er.1.�Contr�ct*or,�i�uii-',Ib�i;emplbye�l�toT(construct,,
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,�10e�:sewerllni ..cover -any.'portlom,ofisewer before It: hasqbeen,'i.nspdcte&,
t "WIli rform4fin!,cit Mght-of-Way . -Per . mIt`:6bt'ajhAbI'�.!fi�nrjhe �Clfy�,.I�
,14OTE �No; !T e y,N�ht-bf wa;y.'requi: rjjlneer�sl office-,
*i�rk,,pd res an
'in,.fulll d -e,%14U*61.'030,&n 6n�'youwlgwpeiml
W T-El,,Noi,�ziLb�ta tnformatiow,regarding,,Or inanc dl-Regulati6ns-:governing isfq�wee,"rs;4'h
0
, '4�'Top)�6f,!Mde;lsewerl must)have,at Ieast,30 lnches� coveraje,�&Op�operty, �lin6�and!'12,:iriches-inside,,property 1ine;l minlrnum�,,
:140TE).No,' grade��of"25'o' !�q h��idsj int igrade,
]:�sharper,)thaxi` ��.willl-be,,permitted.-
NOTEI No,.,J5--Tiendhes0n �fitredt'-,i�ust.,,be�'..w�aie'r',�,"set.tied� and surface:,o;f.Ar'�ei T"iored to ofik'Inal',icondition'.. 6P'ntikc�ors. shallj A:�;,resp'oin'sibie' fbi,.fallurehfdue!,to� im,proper
�work:wkil'ch, may,,developt within -one -,yea . r- of completion.
It
-NOTE); Vo;, (6L ',It ' IsAuniawfull.,to altei4oi4 d6�k�"yother wor thazr-;Is1,p�oyfded[ for,in .:the��perralt,,�,qy�tb;,doiAny,�,w!Drk on'the-�main.,sewert(or'-Its�
�urte�arice�,,except tbi in
.,isert ,the,'?Pipe,.into�,the,.,;�ye.,'..
-P By.
.............. ........... Date' ......... ...........................
DISAW SO �Qj..Mate ........ �Date B
Y
.... ....... ................ ................... .........................
-RPP,.ROV)ED1',-
................................ ................. .. .......
................................... . . .. ...... ........................................................
........... ........................................ ........................................ ............... ............. ............... ......
. .................. I ........................... � ..................
S. e,Signe& By, �Owner Perforrhing(i onstruc.t'ion�.'.PRIOR',,�,o�,Ri�qu!est,,,,I -.77 7
,'M� ui� Q T
et;s e e
wer,*ihstEillationt�cons�t-ru6ted�iiii'der�5t.hisi)p��rmiiI
....... ...... ...
ner-61 Con t ractl rig, Firm�'P6rfGrml n g .Con.t Fuct Ion,Y-,
W. t��
herCit�, oVEdmon�6:�_
AOre�l:in,;acj�oKdance: , 'I ning,,ordujaAce_§,%;Pft
Dat6d� tiii�::_ Z ;of. ....................
(Ckeck�BEFQAX lJE]', -eIep�onp)�101,� ower',!E], erlo
T 8 ibth
bATE RECEqj
F-PERMIT EXPIRES
'CITY OF EDMONDS
USE PERMIT
ZONE
7CONSTRUCTION
NUMBER
PERMIT APPLICATION
JOB SUITE/APT#
ADDRESS
OWNER NAME/NAME OF BUSINESS
PLAT NAM E/SU BDIVI SION NO.
LOT NO.
L�D NO.
L D FEE $
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cc
W
MAILING ADDRESS
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Apprmed 0
RW Permit Required 0
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6,
0
�,o
EXISTING — PROPOSED
Street Use Permit Req'd 0
Inspection Required 0
Sidewalk Required 0
Underground
CIT ZIP
TELEPHONE
/2F
REQUIRED DEDICATION— FT
Wiring
.926
required 0
NAME
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES 0 NO 0
z
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ADDRESS
REMARKS
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L)
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
a
z
W
CITY ZIP
TELEPHONE
NAME
ENGINEERING REVIEWED/DATE
ADDRESS
cc
0
FIRE REVIEWED BY DATE
uu
CIT ZIP
cr X_
TELEPHOt4E
D V
z
0
VARIANCE OR CU
SHORELINE OR ADB#
INSPECTION
REO'D
BOND
IPOSTED
STATE LICENSE NUMBER EXPIRATION DATE
I=
0 YES 17-1 NO
SEPA REVIEW
COMPLETE EXEMPT
SIGN AREA
ALLOWED PROPOSED
HEIGHT
ALLOWED PROPOSED
P OPE�RY/AX ACCOUNT PARCEL NO.
2
I
I
,
EXP
NEW RESIDENTIAL PLUMBI NG MECH
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (FT.)
FRONT SIDE REAR
PROPOSED SETBACKS (FT)
FRONT URSIDE REAR
1:1 ADDITION 0 COMMERCIAL o COMPLIANCE OR
CHANGE OF USE
z
z
PARKING
REQ'D PROVIDED
LOT AREA
PLANNING REVIEWED BY DATE
REMODEL C3 APARTMENT SIGN
E] FENCE
REPAIR GRADING CYDS ( FT)
REMARKS
DEMOLISH E] TANK Ej OTHER
z
E3 GARAGE ROETAINING WALL RENEWAL
CARPORT R CKERY
0
P
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
CHECKEDBY
JTY/P�,OFCON,STRUCTION
CODE OCCUPANT
GROUP 5
1`4
NUMBER
OF
7UNITS
NUMBER OF
DWELLING
CRITICAL
AREAS
SPECIAL INSPECTOR
AREA OCCUPANT
0
STORIES
NUMBER
REQUIRED C] YE
LOAD
PRK T? B 0
DESCRIBE W E
77��,-
711
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D
1/cl.:�,—, e—w
'Y I
-74
VALUATION
FEE
PLAN CHECK FEE
HEAT SOURCE GLAZING % LOT SLOPE %
BUILDING
PLAN CHECK NO: VESTED DATE
PLUMBING
tO
MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t:
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
GRADING/FILL
2
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
STATE SURCHARGE
W
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT: 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
ENG. INSPECTION FEE
W
_j
;APPLICANT,
N INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
LANDSCAPING
2
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
INSPECTION FEE
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
RECEIPT
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
_j
0
X1
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
RECEIPT
TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRLIC-
This application is not a permit until signed by the
CALL
TION: AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
Building Official or his/her Deputy: and Fees are paid. and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
SIGNATUA VVNEFJ..bR AGENT) DATESIGNED
I
OFFICIALS SIGNATURE DATE
(425)
L/
I 771 -0211116W
"fk)
—RWLEIASED BY R.ATE>
ATTENTION
EXT 333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A
FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI_
ORIGINAL - FILE YELLOW - INSPECTOR
CATE
OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX PINK - OWNER GOLD - ASSESSOR
5/98