17140 SEA LAWN DR.PDFiiiiiiiiiiiiii
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17140 SEA LAWN
DR
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TAX ACCOUNT/PARCEL NUMBER: 100CC302CY0
BUILDING PERMIT (NEW STRUCTURE):n(OKIW5
COVENANTS (RECORDED) FOR:
CRITICAL AREAS: DETERMINATION: E] Conditional Waiver F] Study Required E] Waiver
DISCRETIONARY PERMIT #'S:
DRAINAGE PLAN DATED:
PARK.ING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
PERMITS (OTHER): -I'
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN. DATED:
SEWER LID FEE $: LID #: ;?(A
SHORT PLAT FILE: LOT: BLOCK:'
SIDE SEWER AS BUILT DATED:
SIDE SEWER PERMIT(S) I #: 3 L02 -
GEOTECH REPORT DATED: -
STREET USE / ENCROACHMENT PERMIT
FOR:
WATER METER TAP CARD DATED:
LATEMP\DS'l7sWonns\Street File Checklist.doc
POSTED ON KROLL MAP NO.: PERM
BUILDING DEPARTMEAIL 670165
Applicant Fill
�3 PERMIT APPLICATIOW Inside Heavy Lines JOB ADDRFS 111sil
NAME (OR 14AM OF BUSINESS) '7
81DE: YARD BET15ACK STREET SETBACK REAR YARD SETBACK I
Iv"Ookcr V -1 ' L �j
I f.,., , t_4
1'7 I'a
MAILING ADDRY-88 61 1'7 i-a
USE ZoNk�-- LOT A VACANT
3 C-'V,91Vf 7— d,4- A/
E NUMBM
CITY (R a, I a
L) ;70 -HEIGHT BUILDING A--xA VARIANCE N 16
NAME
Ali- PLOT PLAN
ki DRE
TRE ' /W
CITY TELEFFRONE NUMBB ET.T. STREET R/W ;�O-FT. DEFICIENCY TMS PROPERTY 0
COMP PLAN ST. R/W r-r.
REMARKS
NAME
CRE
CICED BY ;C
5/9 1v e N
ADDRES19
M=ER SIZE SERVICE SIZE CLEARANCE
CITY TELEFE—Orix; NUMBER i-(
/-4-
=MARKS
Q MUMBER CITY LICENSE NUMBER
TATE LICENSE
r E C
YP,, O�NNCTION4., R
Le &I Description 0! Property (Show Below or Attach Four COPIeil)
PERMI
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A o T 2 Z /7 /1/// 74 ",;cf PERC. TEfT
v. 13 - PL 7- rxiF(f . V 1) 1-
REMARKS
0 F
/,q -F.5r, �12 q) �4
FIRE ZONE TYPE OF CONSTRUCTION STREET IMPROVEM
i -E.
SPECIAL INSPECTOR QUIRED OCCUPANCY GROUP
YES 0
PLAN CHECKED BY
GAS
RESIDENTIAL LrqE
NEW
0 NON.RESIDENTiAL
FRETAINING
WALL
DEMOLISH 11
ALTER EXCAVATE F-1 FENCE
OR FILL L . -x- rt.)
Vr M
REPAIR -mo wI
LIMP. El 'POOL
El PRE
NUMBER OF STORIES NUMBER OF
UNITS 7
W---
V
NATURE OF WORK TO BE DONE
va.1—tion F" Re�elpt No,
Z
Pit. Cheek
L Z'
PROPCSED USE
BUILDING
PLOT PLAN (Indicate Building setb PLUMBING
abutting strects)
_Z21, —1-9
HEAT & GAS LINE
PENCE
D SIGN
t
N
RETAINING WALL
t '9 %-D
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
C:� 71) EXCAVATION Or, FILL
I hereby Acknowledge that I ha,e read this application: that the in- ToT&L A.MOU'.%-r DUE > &
formation given is Correct: and that I = the owner. or the duly authw-
agent of the owner. I agree to comply with city and late laws mgu- ArrENMON APPLICATION APPROVAL
lating Construction; and in doing the work authorized thereby, to person
will be employed in violation of the Labor 006-s of the State of Washington THIS PERIMIT This application is not a permit iintil
misting to Workmen's COMPen-atiOn Insuranue- AUTHORIZES signed by the Building Official or his Dep-
O.11TLY TWED
NOTE: Permit Limit One Year (E3:cePt DF31OLITIONq which WORK NOTE uty; and fees Ewe paid, and receipt is ac
sits3l be completed in ninety days: MOVED -IN BUILDINGS shall be Com- knowledged in space provided.
pleted In six months.)
INSPECTION --DIRECT GNAT
DATE SIGNED
—.410MATURE (TWNFR —ORAGENT) DEPARTMENT
1-7
CITY OF
L EDMONDS DATE 0-
NOTE: Applicant Subject to Plart Cbeck Fcc Pit 6.1107
Tid. Permit , work to be done on pri,rate property ONLY.
Any Coeltructlen on the p hile domain (curbs, ald"nIkii, driveways, FILE
C.) UZII q.1,c separate portn1W.n.
CITY OF EDMONDS
DEPARTMENT OF PUBLIC WORKS
250 Fifth Avenue North, Edmonds, Washington
APPLICATION FOR A SEWAGE DISPOSAL SYSTEM PERMIT
(Submit 3 Copies)
Permit to be issued to:.. -Richard L. nt ......... . .............. . .... ....... ...... .. .....
.......................
For installation at: (street address) _1714U...SaAlawa..arive --------------------------------- ---------------- ------------------------------- I ..........
Addition or Subdivision-. - SiaalaWn --- Tarr&C4_01visian- 9 ---------------- ------- .. Lot --- 2 ... ...... Block ................
Type of Building: New ----- A-,-- Existing -------- .. Single family residence ....... . Number of bedrooms ........ 5 . ...... 1.11
Other: (specify type or use) -------------------------- --------- ---------------- _ --- __ ........... ............................... .................. _ .............
Builder.. ----- Owner_ --------- ----- ___ ----- --- ---------------------- -- --------- Address ------ . .. ..................... -------------- ............................. _
Designer_.�_._R. - Lyon- - Listilacart aq -----_------------ ----- --- Address .94 0
Soil Log Hole No. XA, -Tati. Sand & iAraval W' ter..�._45_4'
L........ .. loam ---- -------- -------- _ ---_-_-_- .............. .................
Soil Log Hole No. A 33". . GrAy ... Cldy-� ..... tAen ......
t
------- Gray .. Clay ... I.V! ... k"_Ur., - ----- -------
__ -------- ___ __---------------_-- ---_---------_----_---
Elevation of Water Table, if encountered. (Distance from ground surface) .40fte ...
Corrections to control surface water if needed... F.wli ag --- drAi as. -I.
down.. sputs ... to.-stom—sewer .. oil ......
... Wo.. X41 1 .......................................................................................... ........
........................................ ......................................
Specify if any removing or grading of topsoil in field area..910JU! ...
U.. O..00O .. � j w q _ a no. Y. 4
out ... f row .. f Out)" .0.1� ... lotle ... usad ... to ...
lavel ... rear ... t_am ao ...............................
Percolation:
Test Hole No. 1 —Average Rate ........ QA ....... N0.5 17,3
'612,
(Fall in minutes/inch-bottoni 6" test hole)
ft, - 0
Test Hole No. 2—Average Rate ..... 3.0,.D ............. --- ----- _ .......... ....
(Fall in minutes/inch-bottorn 6" test hole)
Test Hole No. 3—Average Rate ...... 1.6...0. � ------ N.O.*.7 1.6..-0-
.(Fall in minutes/inch-bottorn 6" test hole)
4--- 14
Average percolation rate on which to base drain field design ...... 11M.- Date Taken. -4/.24/67-...
Septic tank requirements based on present rules and regulations:
Septic Tank Size --- 12W ......... ... ..gallons.
Amount of Square Feet of
,,,Dispos�j, Field. -__ 95.0 ... r4gw-�:'
Signature Designer'_�_,._' ...... ......... .4 ........... T� ..... ----
"77' —Dat e ------- AP-ri 1
---------- -----
DO NOT WRITE BELOW THIS LINE (To be completed by Issuing Agency)
Permit issued (date).. .... � _ 14.,-1 ................. __ ......... .-Permit Number ----- 4- el ..... _ .... .........
Remarks: .....
.......... .
............................................................................................................. ..... . ...... ................. ........
F L E
September 1, 1972
MEMO TO: School Walkways & Crossings
FROMs Bill Him
Assistant Engineer
SUBJECTi Children 9 BLacle ��alkw_Ws
I not with and talked to Mrs. Dalbey of 17140 Sea Lawn Drive.
She is interested in providing a walkway for children along the south side
of 171st Street S,W. from Talbot Road to 76th Avenue W. We discussed
providing 12" Concrete Culvert for the existing ditch line and backfilling
for use as a walkway. The property owners would purchase the culvert and
the City would install the pipe and backfill as required.
She will contact her neighbors and then proceed. She is very
concerned about children and safety. so I think this project will be a goll
WJN1mjf
m
A
mr, Richard'L. Moofty
0140 sea Uma Orivs
ummu, woshis4tou "020
STREET
May w 0 1969
Tbs Oity of IdpwWW bas r"olvsd a ""140tt
relativ* to the all ea tbo m*%th Wo of your vro"VO w4rofth-
in& 00 y9w twj&Wpw#* lot# Tbj* is to *W" rm that U064w tho
City of jdam" ""0 out* "d fills, *b9old be sot b"k frm tb*
pre perty limm a sJuUms of a 14*t sad * halto fttalatag V*116
may be ussid to "dwA tb* roq"r*d sotb*4 mbeft s"revW by tho
BuildinS OfflAiSlo
it i's revagew that Im tak'a tho
mw*s*mxy vtops to rtAtWo tb* rA Of t" fill from Yew
pr"arty on the *AI*44*t lot.
LWW38114
cc: mrso Halvorson
Very truly "arso
� '10mon
[!Ma:IziA
W4 j* SIAMOM
*A"Ift Ott"tal
mr, Richard'L. Moofty
0140 sea Uma Orivs
ummu, woshis4tou "020
STREET
May w 0 1969
Tbs Oity of IdpwWW bas r"olvsd a ""140tt
relativ* to the all ea tbo m*%th Wo of your vro"VO w4rofth-
in& 00 y9w twj&Wpw#* lot# Tbj* is to *W" rm that U064w tho
City of jdam" ""0 out* "d fills, *b9old be sot b"k frm tb*
pre perty limm a sJuUms of a 14*t sad * halto fttalatag V*116
may be ussid to "dwA tb* roq"r*d sotb*4 mbeft s"revW by tho
BuildinS OfflAiSlo
it i's revagew that Im tak'a tho
mw*s*mxy vtops to rtAtWo tb* rA Of t" fill from Yew
pr"arty on the *AI*44*t lot.
LWW38114
cc: mrso Halvorson
Very truly "arso
� '10mon
[!Ma:IziA
W4 j* SIAMOM
*A"Ift Ott"tal
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OT -A LA WN
1911y. 00 7'L Z 5 E
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'Lim' I T OF� DRAIN
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I K G1 N E ER I N G
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SEWAr.l= ni Dt-Ne
Septic Tank ....... __gals. /A L r E. M
Disp. Field ...... ------- CITY OF EDMONDS No. . ...........
---- sq. Department of Public Works
Other
Name ---------
---------- ................ - ------------------------------ is hereby authorized to install/
repair sewage disposal system at
--------------------- ------- —ICA
-----------------------------------------------------------------------------------------
i I
Date issued on ...... 6.
- S_ 15 - I - -1 ---------
tiol� ate of issue
Permit expires one year
DO NOT COVER BEFORE APPROVED BY DESIGNER OR SANITARIAN
I hereby certify this system was installed under my supervision and control and complies with all provisions 0
of Edmonds Resolutions. f the City
Signature of Installer
A- 4 ......... I ----------------------------------
. 1-1- , - LJ Disapproved El Date -------------------- ___ .............................. _ .... By ---------------------
Remarks:
SANITARIAN OR DESIGNER- ------- -------------------------------------------------- * --------------
This Permit shall Date -----------------------------------------------
be posted in a reasonably conspicuous- place Qn the job until inspection has been completed.
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ELD AREA 1714 C) 5 FALA W N
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Ric L:,Mo o't4 ey
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SE*ArTLF, WASH,
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CITY -OF EDMONDS
DEPARTMENT OF PUBLIC WORKS
250 Fifth Avenue North, Edmonds, Washington
APPLICATION FOR A SEWAGE DISPOSAL SYSTEM PERMIT
(Submit 3 Copies)
Permit to be issued to: ... RJ _chArd.. L..-. -m-oo.n.ey ................ .......... . . .....
For installation at: (street address).. 17 14.0 .. seal awn --- Dri-ve .............. ------ ------------------------------------------------------------------------
Addition or Subdivision ... Sealawn._Terrace--Division -- 8 ---------------------------------- ------- Lot --- 2 ........... Block ................
Type of Building: New ..... X.... Existing ............ Single family residence ................ Number of bedrooms ------- 5 .................
Other: (specify type or use) .................... ................ ........................................ ................................................ * ............... .........
Builder....... OWIler ....... ...................... ----------- I ........................... Address .... ........... ............ _11 ....... ........... I ............ ..............
Designer. C, R. . Iyon, -Enginee ring -------------------_-----_- Address Box ... 187__Ly.n_nwood,..Was.h ..... 9802.0
Soil Log Hole No. XA..--10.1-1 ... Dark-.B.r . Ioam-,_ .38" Jan -.Sand. &.-Gravel .... Water..@ ... 45 .................... ...
B- ----- ?_3'....Br._._Sajidy --- Loam ---- 25_'.'___Gray_ --- Clay . -------- ............ ................................................ I .............. I ........ ...........
Soil Log Hole No. 2,.(:, ----- 15"Ar...-San.dy --- Loam 33.'l ... Gray..Cl&y . . ..... D _-_ 10"_Br.....Clay ... the-n ......
------- Gray --- Cl-ay --- 11.E.11 --- B.r.---@ --- Lo-ani ---- 3_r5"___Br._-.Sandy-.__.. ................................................................ ......................
Elevation of Water Table, if encountered. (Distance from ground surface) None encountered injield_area
... ............. .
Corrections to control surface water if needed ... Footinq..drains --- &Aown ... spouts ... to .. storm ... sewer..on .......
Alle..Vest . ................................................................ .................. ............................ .......................................... .....................
Specify if any removing or grading of topsoil in field area..01d ... f fl. I ... to .. be ... remove.d ... and..san.dy ... gravel .....
..cut ... f rom ... f oundati-ortAt...ea-st-side ... of Jot -be --- used.-to.1eve.1 ... rear --- lot ... area..., ........ ......................
Percolation:
Test Hole No. I —Average Rate ...... �QA ------ No.S. 17.3 (Fall in ininutes/inch-bottom 6" test hole)
No.6 12.0
Test Hole No. 2—Average Rate_ --- 30,0 ............................... ......... (Fall in iiiinutes/inch-bottom 6" test hole)
Test Hole No. 3—Average Rate__W�.Q No.7--16..0 ...... ....... (Fall in minutes/inch-bottom 6" test hole)
. 4--- 14
Average percolation rate on which to base drain field design . ....... Date Taken 4/2-4/67.-...
Septic, tank requirements based on present rules and regulations:
Septic Tank Size...1250 ......... ..... gallons.
Amount of Square Feet ot,�jsj:fb�A�eld ... �9 50 - . reg,,:_:::::::� -
Signature — Designee __-:����ate ----- Ap ri . I - - 2 5-,.,1.96.7 - ------
DO NOT WRITE BELOW THIS LINE (To be completed by Issuing Agency)
Permit issued (date).... ............................... ... Permit Number ...... V?.4r / ............................
- - - -------------------------------------------
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 7
0
CITY OF EDMONDS
DEPARTMENT OF PUBLIC WORKS
250 Fifth Avenue North, Edmonds, Washington
SEPTIC TANK INSTALLATION PLAN
(Subnat in Triplicate)
ADDRESS OF PROPERTY ....... 17.140..Sea...Lamn --- Dr.%_ .................................... Lot No ..... 2 ............... Permit No .... �;11 .....
Owner ... Richard - - L..... Mooney. . ........... ........... . Address. 14312.. Evanston.. Ave ........ .............. PhoneEln 2-40-7.0..
Builder-SaMe ......................................... ... .......... .. Address.. ................ ..... ........................................... Phone .......................
Designer._Qe ... R....4ypn Engineering .
Address P.O. Box. 187. . Lyn n*Qod.,...W5tn.. Phone.7744159_1
InstallerSanie................................................ ......... Address ......................................................... .......... Phone ........................
I hereby certify the accompanying drawing is an accurate representation of the system installed at the listed
address. I also certify all recommendations and restrictions (concerning plumbing stub elevations, maintenance of
grades, fills, surface drains, etc.) listed 'by me my sewage. disposal systei rmit application dated ................
. ....... .... ................................. have been complie ith.
---------- ------ ........... ........................ .......
Signature of Design r Date
TO BE FILLED IN BY CITY ENGINEER ONLY
Accepted.................... ........ / ................................ Date....
Not Accepted. . ......... Date ..... ...
Signature- of Snrii� ... ........ .... ............. ... .. . ........... ..... �_4_) .....
..............
Remarks:.. ....... . ...........................................................................
INSTRUCTIONS: Use the reverse side of this form for the drawing. Use a scale which will permit the greatest
detail and still contain the entire site on one page.
ATTENTION HOME OWNER:
Your septic tank has limitations! It was designed and installed to care for an average -size family. Over-.
loading the septic tank or disturbance of the drain -field may seriously impair satisfactory operation. Points to
remember:
1. Have your tank checked periodically to see if pumping is necessary (2y2-3 years).
2. Do not channel ground water, surface water, footing drains or downspouts into the tank or drainfield.
3. Do not excavate, fill, place a structure, driveway or,patio in, on, or over the drainfield.
4. Limit toilet fixture disposal to sanitary wastes and toilet tissue.
5. Detergents and bleaches used in normal household quantities will not hariii the action of the septic tank and
disposal field.
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'LOT Z 5EALAWN
Llmj-l-�)OF DRAit\i TERRACEJ Div, 5
APEA 171 A() ':� C- A I At,) h I
D r j v E
OWNER B U I LQIFF F:
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R iC H A R D
140112 EVAN5-FON Avi:
M, ?-4 0 70
SE-ATTLE, WASH,
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E li G I N E E R I N G
L Y N NWO 0 01 WN.
The City of Edmonds
APPLICATION
for
SEDE SEWER PERNaT
NEW CONSTRUCTION [:] REPAIRS C]
ON;rNER ..... L .......... ..,v ........................................
ADDRESS ... ...........
uj
0
�-01 I 110!A - 526 1/ 1�
CONTRACTOR ..... ....... ....... .... PERAnT N
LEGAL DESCRIPTION: LOT No . ............ 1:2 ............................. BLOCK No . .................. .........................
NAME OF ADDITION ........ ..................
APPROVED
MAY 5 1970
Approved:
................. B .... �e ............ gA.ktp7—
�Y- ......... *--* ...........
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CITY OF EDMONDS
CIVIC CENTER — WATER -SEWER DEPARTMENT Call FRospect 6-1107 when work
Is ready for Inspect -ton. (No inspec-
SIDESEWER PERMIT tions Saturday, Sunday or he - N2 3702
ADDRESS ....................... 17.14.0 ... S.e.a.lawn .... Drive ...........................
.. .. .... .. .. .. .. ......... ....... .... ....................................................................................................
OWNER ........................... L ......... M ... o.n. ... n ... e. Y ................................... CONTRACTOR .... jjYAV�
Permission is granted ... MAY ... 5 ......................... !_ 19.7Q.., for ......... .............. days to REPAIR or CONNECT a side sewer
with City Sewers In accordance with application oil file and governing ordinances.
ATTENTION IS CALLED TO THE FOLLOWING:
NOTE No. 1—The owners of the property may obtain a permit to construct sewer Inside property line. A licensed Side Sewer Contractor must
be employed to construct side sewer in street area. Do not cover any portion of sewer before It has been Inspected.
N No. 2—Obtain full Information regarding Ordinance 11.16.030 and Regulations governing side sewers when you get permit.
N�_,' No. 3—Top, of side sewer must have at leazt 30 inches coverage at property line and 12 inches Inside property line; minimum grade of
No bends in grade sharper than 'A will be permitted.
NOTE No. 4—Trenches In street must be water settled and surface of street restored to original condition. Contractors shall be responsible for
failure due to improper work which may develop within one year of completion.
No. S—It is unlawful to alter or do auy other work than Is provided for In the permit, or to do any work on 1he main sewer or its appur-
tenances except to Insert the pipe Into the wye.
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JULY RODERT & JANICE WARREN
2005 5CALE: 1" = 2U 17140 SEALAWN DFJVE EPMONP5� WA
I I "', 2ao7�57,115��5
REECEIVIrrl
"'YO 3 200!i
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.-L.0-5- PERMIT COUNTER1
FAUIL MON50N DENGN INC. 425-47&-034,0
FAX 425-4-69-8345
ST ra - F ILE
Ri:ET 17 A0 le a 1 amn ' Drix-ve,
Edmonds,, Washington 98020
January 3, 1985
Mr, Jim Adamap Gity Engineer VtECE I NJ ED
City of Edmonds oc�
250 5th Avenue North
Edmonds,, Washington 98020
Dear Mr.. Adana, voga%'RG
The undersigned residents of the north end of Talbot Park
request an estimate of the cost to put telophine and
utility lines underground.
The lines we are interested in are located on Talbot Read
from 171st street south to (and including) the pole at the
south -and of the property at 17140 Talbot,.Read.
We understand we have no obligation to go ahead with the
project after we receive the estimate ant that the estimate
will be free,
le( —S-1 X9 k4 S�7 Y--
STREET FILE
CITY OF EDMONDS
200 DAYTON ST. - EDMONDS, WASHINGTON 98020 a (206) 771-3202
DEPARTMENT OF PUBLIC WORKS
kz� W—aza,
HARVE H. HARRISON
MAYOR
February 16, 1983
Mr. Wayne Baldwin
Wayne Baldwin Agency, Inc.,
PO Box 130
Bothell, WA 98011
Dear Mr. Baldwin:
As per our telephone conversation of February
8, 1983 regarding the sewer problem at 19830-76th W
Lynnwood, attached are the papers you,requested and
the maps with the address 19330 76th 'blighlighted in
yellow.
Thank you.
Sincerely,
AB/pw
Enclosures
MFUMEL (I L DT
Archie Brena
Water/Sewer Sup'ervis'or
tA- Z
MAXCH DT
IN,
/9311 1940f 19400 1933Z )i 9331
00 0
19411 94 07 19408 19407 1 194"
1"" Sr 06 407
19406 11414 11415
I " 1942f
19419 9413 194V
14 19428 J1497
19TOO 19501
It
FO 9409
19501
W1 MAPLA WO*D,' 4 07 1951
> 0511
ASIPM*IAJW IVTOS 95 0 19fig
CPO 10A cm 10 14 11 ML
9572 9S17
Iff %A -
I 19fr3 1 )9s*o
4 00
196 Tu
V T.
so
MIT
pg&q
P% If.21 U —
if loaf 116ins �TA
V 1
MIS 194" N
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RECEIVED
Wayne Baldwin Agency, Inc.
All Lines of Insurance FEB 71983
P.O. Box 130
Bolhell, Washington 98011 ENGINEERING
0
Phone 362-7557
February 5th 1983
Mr. Jim Adams,
City of Edmonds,
Edmonds, WA 98020
Dear Jim: RE: Claim from M. D. Dalbey
We are referring this to you and attaching all documentation to ayou can handle
with your carrier or self insurance as you see fit. -
His claim is for $85.73 plus 341.97 for sewwx back up in 1980 and 1982, which
we understand is your responsibility.
Please take cave of Mr. Dalbey.
a
Wayn
Claims Rep. City of Lynnwood Inc
cc: Mr. M. D. Dalbey,
17140 Sealawn Drive,
Edmonds, WA 98020
cc: Mr. Robert Noack
city of Lynnwood,
19100 44th West,
Lynnwood, WA 98036 REF CAC 22N 83-2
(\j
C
TO:
DEPARTMENT
0 CITY OF LYN14WOOD
blic Works
CLAIM FOR DAMAGES
(INVESTIGATION REPORT)
0
CLAIM NO.: CAC 83-2
DATE: 1 �'l 1 -83
NAME OF -PERSON OR FIRM Dalbey, M. D.
ADDRESS 17140 Sealawn Drive, Edmonds, WA 98020
ALLEDGED DAMAGE Sewer line damage which happened on Junp-20- 1980_&nd
December 1, 1982. Bills from Apple Plumbing & Heating -and A Rescup Rnntp
attarhpd
OFFICE OF CITY CLLRK\VQ�
I NVESTI GATED BY— (/.-�Qfvlft) DATE:
CONDITIONS FOUND: 741':�, MA10 (2,�tDNG5 10
2TZ::� a y? � N r2
REKARKS:-P�we-:L, -i�D,-noN I . _,U,
14D P—ARTMENT HEAD
Form 014-168
2-5-31
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Referred by:
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Date P.M.
P pie Plumbing& Heating
Phone 774-2753
P.O. Box 3226, Lynnwood, Washington 98036
—Complete Service and del - 24 Itlour Service 15 9 3�-.
—BUS. PHONE
JENANT ----PHONE
LA R Yey
DESCRIPTION & MATERIAL
AMOUNT
FROM:
TO
I HOURS
6-d
dr)
AlelArIV., dr 116V�-e Y6 &V qd. r4 (;Vwa fpAlef t;F
�e.04
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TOTAL HOURS7,5V
A
40 "/,d
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HELPER
Hrs I $
S/0
A ftxoll�tVj,)�JJAC(l
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TOTALLABOR
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d-11 As 0)
.1OTAL LABO'.%--,A
To Our Customers: Service bills are due and payable upon completion of work and serviceman is authorized to receive payment for same. If
service is not satisfactory in any way, please phone our office immediately.
Work performed on or about plumbing fixtures, supply lines, drainage and heating systems, sewers, etc., is not guaranteed against stoppages,
damage in the removal of foreign objects, backups, floodings, breakage, fractures or freezing. New fixture installations are guaranteed against
faulty materials or workmanship for a period of ONE YEAR from date of installation.
Highest legal rate of interest charged after maturity. If, however, this account is not paid as agreed, I (we) agree to'pay in addition to t�e fore-
going, a reasonable attorney's fee, or if this account is placed in the hands of a collection agency, I (we) acknowledge that you will be damaled
thereby to the extent of the collection charge against you and I (we) therefore agree to pay to you, as liquidated damages, an amount equa to
the amount charged you on said collection by said collection agency, not exceeding, however, fifty percent of the amount unpaid thereon, and
also a reasonable itt I f _At the optior=IZAreV, Oe venue =fd may be I f h h d
Custorriier's signatis
PERMITS
SUBTOTAL
S��LESTAX
TAIL
INFOR�\tATION REQUIR%BY CITY OF LYNNWOOD IN OqbR TO PROCESS
A CLAIM FOR DAMAGES:
NAME:
ADDRESS:
TELEPHONE:
LIST OF ITEMS DANLkGED:
- < EcA
n 'A 4 - S91 K, �j 1. 2, 111)
M! L4 V
rvi (-1 -1
DESCRIBE HOW DAMAGED: Qlt94 rr'3
(if possible) 0 UAA in 4-,
DOLLAR AMOUNT OF DA�AGE: (-Lj,jk--e—
DATES DAMAGE OCCURRED:
11133
cay of LYNNWOOD
Sig a ture
1,k" --j I
Form #014-136 ��te
7/30/75
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PUBLIC WORKS DEPARTMENT
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