17125 66TH PL W.PDFiiiiiiiiiiii
5228
17125 66TH PL W
City of Edmonds
Development Service's Department'
Planning Division
Phone: 425.'771.0220
Pax: ,425,771.0121
Date Received:: 31-710(
City Receipt#:
Critical Areas File#:
CriticalAreas'Chdicklist Foe: $135.00'
Date Mailed to Applicant:.
TheCriticil Areas:Checkli§t. contained on this form is.to A,.ptoperty ..owner,..or his/her: authorized'. reptesentative,
be, filled out. by any. person� preparing a Development must.*fill, out the checklist, sign date it-, and submit it
e wi , re ew -hedklis ,
Application- for. .:City of poor: to,� to the'City. Th Cify,� 11: vi� :A&C t - make 'a
Permi the
d of' the
his/her submittal of the,application to the City. ,p�ec pry. -,site. visit,,.,an. , make . a.�.deterinination
development
f tlil* enable,-Citv.� staff to... subsequent -stops, necessary. to conip ete: a
The.,purpose. o e.Checkli�t is to
�ermit-app ication'..-
deternfine' whether any :pofenfial Critical Areas are, or
mA_ be` esenit on't the, subWcfproperty ,-Tbe- * fbrindtion�.� 4he'si6ed_c
y PT in. Please gitbrriitz vicinity. map, -alofigwith Opy
I -te: the-Che ff
needed.- to.. COMPP qklist should:1 be ea o,assis,vCitxi.,sta m,fffidig locatink the:
a''bie", he q'i y� !,:,:,q.
avail om ob�etyatibns.,of the, sitebr.&ta. available tit �'specifiic:�p'lece�of.�.pr.operty.d!pgc'n'be'd:on�,�N.�',f,�' 'm
C .
ertin. - t
includ6:,. other. - -p en
11 aL -'niaps, �-,or:. o d n
jt�. Ra .(Critic' areas inve s' il !.,.,.a difid , -,th& applicant �shall'
site, p an,
surveys),, nformatiprli Je.g.. topography. mapj etc,) or..
iun666n'.With:this.-Checkligt,,t6.�Lssi§tarit'staff
ment�of the'sit�-.'
iii'completiri�Oidiz:,t)relirm*n assess
aTY,
eirsi and I n on the pi .`of the applicatiori'ag'rees,
e undersignod:appli6aht.. and!-his/her/itsh �assi
gnsjJnIconsi. rocessmg,
.to-r6lease,:,:indemnifY; defend and hold' the City.... of -Edmonds -harmless from any. ges,:
and,all 6 rna' -** lud. g -reasonable
mc
f
attorney s ees; ansing �from- any. -actioh�� or, infraction,-,,be�sed,in.",,�rhole of". aitupoii.Jals6i:mWead� i, inaccurate or
p
I mplete:inforr . natio 1' . applican viiislfie�r/its. agents or emp, oyees
nco nlfuinlsh6a y_he� t,
gignaturei-I certify that the*,info e_ihibits,herewith,�submitteid_ af6,Iru6�afid::correc( to,the,, bestl':�of_my.
zd
to
knowledee� and �that I am Author fil S.'applicatiqfi�orrthp.,�ehalf of the owner as! listed below
-9 E ;2
S164XT uR-E,, Q AP,P'L'ICANT/AdENT.. r-l"I, ,4 AT
Pro &ty.,Owner s Authoriiation
B y- my signature, I certify that Ihave autho'h2ed Above ApplicanVAgen to a' Ply fbithe��subjdct land.use.,apolidation
p
-,aiidLgrantmy,pqmiission'for.tli&piablic-offici'ils.iindthe:gtiff.-of.the,City'6fEdmori&:tb.eiiter'ihd subject,pro I perty f the*
or
purposes of inspection and ttendant to thisapplication—
'po��
ATURE OF OWN E*R 6AIt rN 0 U.:
giGN
PLEASE PRINT CLEARLY
Own6fr/Applicafit: App&ant.,,Reptiese' tati*46:.
CA File No:. C(O
Critical Areas Checklist
Site Information (soils/topo
graphy/hydrology/vegetation)
1 Site Address/ Location. I 10--5 ub—`� W EAW10-J3
2. Property Tax Account Number:
3.- App'roximate'SiteSize (acres, orsqu�are feet):
4.. Is this site currently.developed? yes; no.
rt S A c,(-
If ye de 616j)ed? k
how is site ev.
.5., D7e the greneral site:t6pography. Check all that apply.
Flat: less than 5-feet.6levation changeover entire site.
�s o ally less� than 15% (a vertical rise, of 10-fe ontal
Rolhng:,,. slope n, et over, a onz
disifinc6slbf �6646et).'
1�: 'sl --W-bf ie��thih-15%�-a'ndl'e�sthan,30% (a, vertical rise of 10-feet
9pes.:presen onSile MO
horizon
-over a 'tAdistance�of-33to 66-feet).
0 greater-Ithdit -30%.piesent on site -feet over a horizontal
g� fades *',' f (a vertical rise of 10
Aistaiic,�.bf Mss-than �34660,
Other (pl6ase'-describe'
lz�
4. Critical Areas inventory �r-,t.A.,-ma"p'iri'dicat6�'.Critical'A-re'a on'site? 226LkO.
5. Site within designated earth subsidence 1andslide hazard area?-' Mo'.'
DETERMINATION
W__YD REQUIRED WAIVER
bV.- Date: ---k' At lnl—
Reviewed
Unncal Areas Checkhst.doc/4.222UU3
CITY OF EDMONDS
CRITICAL AREAS RECONNAISSANCE REPORT
Site Lo6ation:
17125 _ 661h Place West
Tax Acct. Number:
00478300000200
Determination:
Study Required
Determination #:
CA-06-27
Applicant:
Budget Tank Removal
Owner:
Paule Selle
CRITICAL AREAS RECONNAISSANCE REPORT: STUDY REQUIRED (CA-06-22)
During review and inspection of the subject site, it was found that the site may contain critical areas,
including Geologically Hazardous areas, pursuant to Chapters 23.40 and 23.80 of the Edmonds
Community Development Code (ECDC).
GENERAL CRITICAL AREAS REPORT REQUIREMENTS
Critical Areas Reports identify, classify, and delineate any areas on or adjacent to the subject
property that may qualify as critical areas. They also assess these areas and identify any potential
impacts resulting from your specific development proposal. If a specific development proposal results
in an alteration to a critical area, the critical areas report will also contain a mitigation plan. You have
the option of completing the portion of the study that classifies and delineates the critical areas and
waiting until you have a specific development proposal to complete the study. You may also choose
to submit the entire study with your specific development application.
Please review the minimum report requirements for all types of Critical Areas that are listed in
ECDC 23.40.090.D. There are additional report requirements for different types of critical
areas (see below).
Note that it is important for the report to be prepared by a qualified professional as defined in
the ordinance. There are options on how to complete a critical areas study, and there is an
approved list of consultants that you may choose from. You may contact the Planning
Division for more information.
General Mitigation Requirements for all Critical Areas are discussed in ECDC 23.40.110
through 23.40.140.
STUDY REQUIREMENT — EROSION HAZARD AREA
It appears that this property contains or is adjacent to an Erosion Hazard Area. Erosion Hazard
Areas include:
* Those areas with Alderwood and Everett series soils on slopes of 15 percent or greater.
Any area with slopes of 15 percent -or greater and impermeable soils interbedded with
granular soils and springs or ground water seepage.
Areas with significant visible evidence of ground water seepage, and which also include
existing landslide deposits regardless of slope.
DEVELOPMENT PROPOSALS ASSOCIATED WITH EROSION HAZARD AREAS
Development within an Erosion Hazard Area must meet additional criteria.
For erosion hazard areas with suitable slope stability, the only critical area study needed is an
erosion and sediment control plan prepared in compliance with the requirements set forth in
Chapter 18.30 ECDC as part of the construction documents. This option is at the director's
discretion, per Edmonds Community Development Code section 20.80.050.G.
In areas where the slope stability is not suitable, projects within Erosion Hazard Areas will
require a report by a licensed Geotechnical Engineer or other qualified professional. Note that
it is important for the report to be prepared by a qualified professional as defined in the
ordinance.
0 Report requirements are given in ECDC 23.80.050, and more generally in ECDC 23.40.090.D.
0 Development standards are given in ECDC 23.80.060 and 23.80.070.
STUDY REQUIREMENT - LANDSLIDE HAZARD AREA
It appears that this property contains or is adjacent to a Landslide Hazard Area.
A Landslide Hazard Area is any area with a slope of forty percent (40%) or steeper and with a
vertical relief of ten (10) or more feet (except areas composed of consolidated bedrock).
* Landslide Hazard Areas are further defined and illustrated in ECDC 23.80.020.B.
In addition to the general requirements for Critical Areas reports referenced above, specific
Critical Area report requirements for Landslide Hazard Areas are provided in ECDC
23.80.050.
DEVELOPMENT PROPOSALS ASSOCIATED WITH LANDSLIDE HAZARD AREAS
Development is restricted within a Landslide Hazard Area and its buffer.
• Projects that will intrude into these areas will require a report by a licensed Geotechnical
Engineer.
• The criteria that are applied depend on the amount that the buffer is reduced.
• The buffer can be reduced to a minimum of ten (10) feet (with an additional 15' building
setback per ECDC 23.40.280) if a report is prepared that meets the standards listed in ECDC
23.80.050. The alteration must also meet the requirements listed- in ECDC 23.80.060.
• In addition, proposals to reduce the buffer to less than ten (10) feet must comply with the
design standards listed in ECDC 23.80.070.A.3.
ALLOWED ACTIVITIES
Certain activities are allowed in or near critical area buffers as specified in ECDC 23.40.20. If you
have any questions about whether your proposed development qualifies as an allowed activity, please'
contact a Planner for more information.
EXEMPT DEVELOPMENT PROPOSALS
Certain development proposals may be exempt from Critical Areas Requirements (ECDC 23.40.230).
If you think that a specific development proposal may be exempt, contact a Planner for more
information.
Jennifer Witzgall, Planner- e!L' March 1-3
Name Signatq��� Date
NOTE: Cited sections of the Edmonds Community Development Code (ECDC) can be found on'the
City of Edmonds website at www.ci.edmonds.wa.us.
2
Pllchuckt�)ntractors, Inc.
Job # 107020298
June 17, 2004
gi-W
Sheet 1/1 Rob Inglis 1-bitatV
< C)GIMMOOiVIV
aV311V
LEGEND < 3NOVVC103SNC
0 28" TRAFFIC CONE
WORK AREA C49
TRAFFIC FLOW
Note:
Due to the short length of the 66th PI
signs will be spaced closer together
than regulation.
b
CY)
LU
0
U
Or)
b
%0
ce)
%*
ROAD
WORK
AHEAD
0 0 00 0 0 0 0 0 00
0 41 M- I Xx 1 0
Notes:
1. All signs and spacing to,tOnforrn
to the MIJTCD and City of Edmonds
Traffic Control specs.
2. Channelizing devices are 28"
traffic cones.
4. All signs are 48" x 48". 13/0 unless
otherwise specified.
5. Alert affected residents.
6. 1 Flagger will control alternating
single lane traffic.
7. Work area will be 15' E of C/L of
66th PI W & 15'S of C/L of 172nd St.
8. Second work area will be 15' E of
C/L of 66th PI W & 40'N of C/L of
I 72nd St.
DRIVEWAYS TO BE
KEPT CLEAR
WORK AREA IN
GRASS SHOULDER
ta-
1001.
I
100
10(
CHANNELIZATION DE\nCE SPACING
MPH
TAPER
TANGENT
50/70
40
80
35/45
30
60
20
40
172nd ST SW
END OF MAIN (2" MPE CAP)
15'E, 38'N CIL—
FIELD LOC.—'N CIL,—'E CIL
PROP. 2 " MPE IP AMIN
15-E CIL
FIELD LOC.—'E CIL
6615
FUSE TIE—IN (2" MPE CAP)
39'E, 12'S CIL CV
-1. C"
-,Z 50'RIW
C7 ZL
.ZX-10a'P O&E
10& .12-S
107008017-00 r
50'RIW
�%". R W
4
04"t 41, T
A
'GRASS' . . . . . .
ASPHA�7! 50'RIW
END OF MAIN (2 " MPP CAP)
18'E, 15'S CIL
2 OP MPE TEE
15'E, 15'S CIL
LPROP. 2" MPE IP MAIN
I 5'S CIL
2" X 900 MPE ELL
39-E, 15'S CIL
PLOT PLAN_
SCALE: 1 "=50'
FITTER (CHECK L30X IF COMPLETE)
Work area left in Clean & Safe condition.
Complete all Pipe Tables and Cos PresSLre Stomp.
Field changes Red -Lined on as-buil t.
Material verified and Changes noted on Paperwork.
All Valve & Tie-in Locations noted on as -built.
Note beginning of Main, EOM & Line of Main locations
Show Rope Locations & Cul-de-sac -Rallus.
Foreman's Signature
Company
DATE
STANDARD GAS CONSTRUCTION NOTES:
1. FIELD LOCATE ALL UNDERGROUND UTILITIES. CALL *ONE -CALL" TWO WORKING DAYS PRIOR TO CONSTRUCTION, IN
WESTERN WASHINGTON CALU 1-800-424-5555. IN KITTITAS COUNTY CALL' 1-800-553-4344
2. ALL CONSTRUCTION IS TO CONFORM TO PSE GAS OPERATING STANDARDS AND GAS FIELD PROCEDURES.
3. EROSION AND SEDIMENT CONTROL SHALL BE PER PSE STANDARD PRACTICE 0150.3200 TECHNIQUES FOR TEMPORARY
EROSION AND SEDIMENT CONTROL AND ANY ADD11IONAL LOCAL JURISDICTION REQUIREMENTS.
4. NOTIFY PROPERTY OWNERS ADJACENT TO PROPOSED CONSTRUCTION ACTIVITIES A MINIMUM OF TWO WORKING DAYS
PRIOR TO BEGINNING CONSTRUCTION. USE ISI TO DISTRIBUTE FLYERS IF JOB IS LARGE, OTHERWISE HAND -
DELIVER FLYERS BE SURE TO INCLUDE THE LIST OF FREQUENTLY ASKED QUESTIONS AND INFORMATION ABOUT
THE OPPORTUNITY TO PURCHASE AN EXCESS FLOW VALVE WHEN THEIR SERVICE IS INSTALLED OR REPLACED
PER GAS OPERATING STANDARD 2550.1600. ALLOW ADEQUATE TIME FOR CUSTOMER DECISION AND RESPONSE.
5. ANY CHANGE IN ROUTE, TIE-IN METHOD OR ADDITIONAL MAIN FOOTAGE MUST BE APPROVED BY PSE GAS ENGINEERING
SERVICES.
6. COMPLETE "PIPE COND11ION REPORr ON ALL EXPOSED EXISTING PSE FACILITIES. CHECK BOX ON REPORT FOR WIRE
BOX (TEST LEAD) INSTALLATION.
7. ACTIVE SERVICES DENOTED BY.
8. PIPELINE MARKERS AND WARNING SIGNS SHALL BE INSTALLED AND RECORDED BY THE CONTRACTOR PER PSE GAS
OPERATING STANDARD 2525.2500.
9. VALVE MARKERS SHALL BE INSTALLED AND RECORDED BY THE CONTRACTOR PER PSE GAS OPERATING STANDARD
2525.2600 FOR ALL HP VALVES IF THE LOCATION IS NOT REDILY ACCESSIBLE. AND FOR ALL VALVES WHERE
PERSISTANT SNOWFALL MAY OBSCURE THE VALVE BOX
10. TO PREVENT ACCIDENTAL OVERPRESSURE OF ADJOINING SYSTEMS, NO TWO MAINS SHALL BE CONNECTED EXCEPT AS
. SHOWN ON THIS DESIGN UNLESS APPROVED BY PSE GAS ENGINEERING SERVICES.
11. SYSTEM MAOP DENOTED BY: ISYSTEM MAOP - 45 PSIG
12. GAUGE AND MONITOR USE OF ALL STOPPERS TO ENSURE ADEQUATE FEED.
13. RESTORE ALL DRIVEWAYS SUBJECT M OPEN CUT TO ORIGINAL OR BETTER CONDITION.
14. GAUGE AND MONITOR USE OF ALL STOPPERS AND SQUEEZES TO ENSURE ADEQUATE FEED. (USE MANOMETER FOR
LP SYSTEMS)
15. RESTORE ALL DRIVEWAYS SUBJECT M OPEN CUT TO ORIGINAL OR BETTER CONDITION.
16. PURGE POINTS AND PRESSURE TAPS TO BE INSTALLED PER PSE GAS OPERATING STANDARDS 2525.3400, AND 2525.1200.
GAS MAiN INSTALLATION/RETIREMENT
Type[Work
Pipe Size
Type
Estimated
Length
Actual
Length
Manufacturer
INSTALL
218
MFW
1121
GAS MAIN PRESSURE & TESTING
TYPE TEST
PRESSUPE - TEGTE;)-13Y--
DATE ON
TIME ON
DATE OFF
TIME OFF
TYPE TEST
PRESSURE
TESTED BY
DATE ON
TIME ON
DATE OFF
TIME OFF
Desi-qn Press 80
SYS MAOP 45 PSIG
PROJECT PHASE
INOTIF#
ORDEIR#
U)
SAP Superior
Service/Meter
Service/Meter
Service/Meter
Service/Meter
Ind. Service
Ind. MSA
Dis. Reg. / FT
HP Svc/MSA
Relocate
Retirement
X377541491
107020298
X597732575
106131177
I Contractor CONSTRUCTION COST CODES:
JOV-103-11 1 F
Project Manager Contact Information:
PATTI NESS
425-327-2783 CELL PHONE
pattLiLesaillipae.com
IREV# DATE BY DESCRIPTION
-3
2
1 1
Vicinity Map
SITE
IMIM
lim
R191
Ownerl Developer Contact Info
PA UL SEIZE
17125 66TH PL W
EDMOND, WA 98026
ATTN: PAUL SELLE
Office: 425-743-7740
CALL (800) 424-5555
2 BUSINESS DAYS BEFORE YOU DIG
THIS SKETCH NOT TO BE RELIED UPON FOR EXACT LOCATION OF FACILITIES
PROJECT MGR
ENGR-GAS
DRAWN BY
CHECKED BY
COUNTY EMER SECT GAS WK CTR APPROVEDBY
SNOHOMISH 4 MNSNHG CP TECH.
1/4 SEC OP MAP PLAT MAP
NE 08-27-04 156.068 158-071 MAPPING
JOINT FACILITIES ARRANGEMENTS
UTILITIES
CONTACT
PHONE#
PUGET
SOUND
EMGY
DESIGNED BY PILCHILICK CONTRACTORS INC.
NIA EDMONDS
CONTACT PHONE DATE
P. NESS 206-418-4237
MLOCK 1206-418-4217
P. NESS 1206-418-4ZS7
P. NESS 1206-418-42.27
PAUL SEELE
2" MPE IP MAIN EXT.
17125 66TH PL W
EDMONDS, WA 98026
107020298
Drawing Number:
NIA
SCALE: PAGI
I " - 50, 1 ly
APPLICATION 10
for
The City of Edmonds SIDE SEWER PERNaT
EASE ENT No
NEW CONSTRUCTION REPAIRS 0
OWNER 5
CONTRACTOR NNOOLF—Y!: npF— PER T No.47.
.............................................................................................................. ........................... ............................
_T P_
ADDRESS 1-71 \NEf> LEGAL DESCRIPTION: LOT No . ..............
....................................................................................................... ................................ BLOCK No . ..............................
NAMEOF ADDITION .........................................................................................................................
-35
*es�4p
lu
=S_rL_le=
r
.1110 WARIPUIMY 0;,'AX-JRAVY The information
o_Vileu mv";X`� ccniijr�Z! fta" by �fiy u! '17�Tlcldls. i':;
consubMs. W,, QI� of Edvs7,A$ c"'Z3 ric? YlUrfUlli i'__
ce",' fort, ci�. Any pz-.'iw or cnt'�' roquez-,
jimIt to,
na", 0)�O A;"d rnq C., f.'.
Edm' cn'�lzi ncr ;"3 r
fc4h- 4"(
Approved:
DA... . .. .. ....... 6 ... ............
- - - - - - - ---
q
'�E _4ER
GIFY.'*` OF EUMS4 01NID-5, SIIDEr,,,
-`� W,
C �WiATEWSE.WER',DEI�ANRT-M-EN-Ti",
E,
T�'
"A'
t
Callf 1.75-25251 ?for sside,isewer 'inspect
lonst RF,179�F, -covering, :any port forv,,of' Ahe, constructi on.
-requst. NQISat�.,-,j�Sufi�,.,or lffollday� �njp ns�
J�spectiom wffl��beoprovldii*dl N%ilthini 24; houq,�after
A ectio
w
'S 6th:::-PTace'We*st.-'
................... : ........................................................ .........................................
*DDRESSMOdkU- -:(CON TRU 1.7 6
'EM02M)DES6, 101 - 2- Hb�v 6
d ei,�ht
..... ................... ............... ............. ....
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IER.AWD�Ok.zBT_ITI-LDER,;..:� .................................
.............................. Karb n,;Se 11 P
....................... ............................................
W,o ONrTme T. OR; SmAm 1�&/ADDRESS .................... y ....... 2')Oth, -I�W �dfiionds Wash*.. '98020:1,
I. C E Ioe.: Wool 6. 880�. -
.............. ............. .............................................. . .............
...................... : ............... .... . ....
October-. 18..
n�ciibw,�6i, `Ee sidb� ts we'rloi iii&,i6wv!�iia-r-y,;, �s�wer,,.,
......... . ................................................. . ........ repalrandj/or,�6n
Ify
(6VEdmondsi;or.dInanceS., w -
kL "EIbVT'0) TIT]tIF0h '0*,,h4G:%.'
..-NOTE1,11M., -IC—.Thei�ow�6rs-t�of��ther)p�o'perty, may -obtain, permit �toiAconstruct.sei�er lnslderproperty,'Aine�_'
Xmcen - s6 - dI Side,, Sewer. co�fracfor,u�u edllo) 6onstruct;
igidb �se*er;lwistredflarew_ Do,jno'V'cov�ranX, -portion, of':sewei ibei6r'e*-it.*",hasjb6bzi,,:I'nipedted�,
KOTEI,Nb:.,�IL,��Iiil w.ork,,j��rforme I dkin6cl y., rl - gl�t - �of-way,xequires�,anr In
vasionlioVAUght-of-Way -pe!:i-iii,tiobCaj:h-�bie�:ii;bm-,tbe Cit -EngineWs',officej, -
Yj
NbTt' foinnat ton 6 '-Regula:t
regaxdlng�prdinancei 141.16�03 Y,andl �onsl 'governing gld'eNscw'ers�.when'- �ow get pernilt:, -
6
'N TE. Nol..,4--�Top,of isideqsewer ;nnust Ihave,a tAe&sf'301 Inchesi,cov lAches,Inside �pr�c;pe'ky,::Iine;,,m�niniur!i-igiadb!�of,,.; ',-/�,.,',Nbt,ibends,,in,,gradei',
erage ' at property IJ.neI*And':j2� 2
:,�sharperoAthanc'A',,willtlbe,,pp�rmittedi..'
-�l,inti'�t-reet,,mtist4bd,-,wat'er;,settledl!and�isurface:,of*istreet',festb�6dt 'to, or�ginaljjco.ditioni �Coi�trahors 'sinaWlbe resp;.onsjbje� k6r'laiiure��due,Aoplmp
,P�.O.T-E Dio�,115�Ti6dfie
'work �W,hich)ma id'evefop)'�Wlehin��one,.yeaL�,,df,compleiibni.": r6perl',.
I�OTFII -No� 41
t;;is��urilaWful�lto.ialte�,,torl,d6�;&nY�,,other,.work ,than, �is,.- provided! for,,Jn Ahe permit �or'46-;do �a 6rk:; n the�;mECih,,,s6v�er,�or.�lts��ELppurte'nafi�6�):�xcppt,��o�,i�,,.
.0
��p!p e, into) Ahe, wye:�
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_)BOT4i Pe n% ie 'gftAdI-.'By
orming,,j ons -ru I PRIOR:To� Requesf-:F�,or,�,�I�ri�pec�t-i'dn�
........ ihereby- certity,thatothe e4s6,Wer,'Jnsta-Ilat-ibii-,Coilst�u6tedf.*%under,,thist.,perniit'.
............
oflContractingirFirm, Performing*
'thal v,
daxide,&%q 1,,jipi 6rriin' rdinand slWA-he,'City, ,'df`EdM6fi6,.
0, e
4
�DPt
edithls�.... of�. .
V! V1 C heck�BEF K YO&Aikj er, ",Tele" S'
wat eweM -_kOth
-e r) 1 ET .-V
U.
APPLICATION
for
k "-M WAM SME 8EVVM PIMMM
The CI*- nf EcIrnonds'
NEW CONSTRUCTION 0 REPAIRS 0
T 0,
OVVNER
ADDRESS
91
EASEAMUNT No.
/—/40/
I .
CONTRACTOR e.0-, �-- -PERMT No.
LEGAL DESCRIPTION: LOT No . ........ z
................................... BLOCK No . ............................. ..............
NAME OF ADDITION -------- ....................... .............
�' (' '& / z-, - 10�
La
-.W - )
.Z// j
711) 4X-e--
oil,
shown cl the
am. consullints. The bity of Ed mon-aii6i�ii warrant tho c-
anyt�m�� set forth or, the map. Any person or entty reques....- a
shoui,, 6onduet an Independent inquky regarding the Informetior
bul, niA limited to, the locail'o'.) ct Z.
Us: may or may not e)dst and may or r,,-..
tf 10�;aiw�i 1� Neither the City of Edmonds not 1t^0
1 1-1 fm the information given on this map, ncrfcr
E oiati oi t provi dad based upon said map
Approved:
DATE........................................ ....... By ... -- .............. -- ............ .. . .......... ............
T
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Cit -,of Edmonds fermit No:
y
001
RIGHT-OF-WAYCONSTRUCTION PERMIT Issue Date:
A. Address or Vicinity o f Construction: 1-71 Z-�5_. LQ
B. Type of Work (be specific): L� C_
5� Is i Ig Lo _PL
�_i TT- i C�_ _s�
LCI\ Contact: sv_o_ (C_\ �L r
C. Contractor:
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Mailing Address: 1,7-A_� &d4Le Phone: -,2C1& /.9,57 JS7
State License #:?(Lc�-tcl 101 iIV7 t4 Liability Insurance: Bond:$
D. Building Permit # (if applicable): Side Sewer Permit (if applicable):
E. F� C El Subdivision
ornmercial CityProject VJ T, OVWD)
04� ftl), VERIZON, PSE,
Multi -Family Si'n'gl6 Family"','411 J S
X
F. PAVEMENT CUT:. Z YES [I NO G. SIZE OF CUT
CONCRETE CUT: El YES [I NO
AN'LICANT TOJU,Al) ANI) Sl(;N
INDEMNITY. Applicant understands by hislher signature to this application helshe holds the City of Edmonds harmless from
injuries, damages or / claims of'any kind or description whatsoever, foreseen or unforeseen, that may be made against the City, of
Edmonds or any of its departments -or employees, including but not limited to the defense of any legal proceedings including defense
costs and attorneyfees by reason ofiranting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOHING THE FINAL
INSPECTION AND ACCEPTANtEOF 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
* Traffic control and public safety shall be in accordance with City regulations as required by the City Engineer. Every
flagger must be trained as required by (WAC) 296-155-305 and must have certification verifying completion of the
required.training in their possession.
* Restoration is to be in accordance with City codes. All street -cut trench work shall be patched with asphalt or City -
approved material prior to the end of the workday — NO EXCEPTIONS.
* Three sets of construction drawings of proposed work are required with the permit application.
CALL DIAL -A -DIG (1-800-424-5555) PRIOR TO BEGINNING WORK
I HAVEREAD THE ABOVE STATEMENTS AND UNDERSTAND THE PERMIT REQUIREMENTS AND ACKNOWLEDGE
THA TIMUSTMAKE THE PINK COPY OF THE PERMITA VAILABLE ONSITEATALL TIMES FOR INSPECTIONS
Signature. Date:
(Contractor or Agent)
FOR CITY USE ONLY
Approved by:. 1�.4_.y7y Right�of-way Feel 160, O�4 A IS,4`0
Time" Authorized: Void ALiter 241-,4/2 ae- 4 Disruption Fee/Fund 111:
Special Conditions: ar att 719 AN Fee: ZA
S,c, Z= P_ co AL b i r ) 6 t4 AJAI"rA#N A 1;'*!SjCrA Total Fee:
4
FQ-.OA.4 ALL CiT-y QF-90"o&,),_-4z ur1i_1-r19:s- Receipt No:'
AL.e A r A FeEc 7—�= ei ,k r—!5 tox-ly rg, i-lu ---,I /y e, Issued by:
r. K!A r X-00, Ad 15; ic rr�a
5 rA R, r k 4) A /6 c > t r, h, r A k' 0, J Z. t A I
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UPON COMPLETION OF PERMITTED WORK, AN ENGINEERING . FINAL
INSPECTION IS REQUIRED PER CHAPTER 18.00 OF THE EDMONDS.
COMMUNITY DEVELOPMENT COT; ne 425-771-022.0, Ext. 1326) -
DATE:/ 27-05
FINAL APPROVAL OF PERMITTED WORK. Ty
"Inspector's Signature
For inspection requirements see Engineering Inspection Information handout.
DAMy Documents\Forms\Engnmg\ROWpermit_.doc
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