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17707 TALBOT RD
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COMMUNITY SERVICES DEPARTMENT
250 5th Ave N
771-3202
use
APPLICATION FOR STREET USE PERMIT
Name of Applicant: �J �
Mailing Address:
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Telephone Number: Date:
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49
Description of Public Place or Portion thereof desired to be used: (exhibit
may be attacr)
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Type.g Use de.sired,to be made of Public Place:
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If applicable, attach plans and specifications for any utility or structure to
be erected and/or maintained on the Public Place:
TEMPORARY PERMIT: Unless otherwise designated herein, this permit is understood
by applicant to be wholly of a temporary nature, that it vests no permanent right
whatsoever. If the permitted use becomes dangerous or such structure shall
become insecure or unsafe or shall not be constructed, maintained or used in
accordance with the provisions of this title, the same may be revoked and the
structure and obstructions ordered removed by order of the City Engineer. If this
application is for a specified period of time, the terms of said application is:
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, foreseen or unforeseen, that may be made against
the applicant or the City of Edmonds, or any of -its department or employees,
includin ' g but not limited to the defense or any legal proceedings including defence
costs, court costs, and attorney fees by reason of granting this permit. In
addition, applicant understands that the City shall -be provided a certificate of
insurance to indemnify and hold the City of Edmonds harmless from all claims
and/or property damage, naming the City of Edmonds as an also insured.
APPLICATION OF CHAPTER 18.70 OF THE COMMUNITY DEVELOPMENT CODE: Applicant warrants
that he has read, or had the opportunity to read, Chapter 18.70 of the Community
Development Code, attached herewith, and understands'that all terms of that
Ordinance are incorporated herein as if set forth in full and this application
and permit therefore are subject to the te�msjof th t Chapter of the Edmonds City
Code.
Applicant's Signature
/Da f
Services Department
City of Edmonds, Communi
APPLICATION FOR STREET USE PERMIT Page 2
Approval (and Agreement, if applicable) of Abutting Property Owners:
SIGNATURE PRINTED NAME ADDRESS
DATE
DO NOT WRITE BELOW THIS LINE (To be completed by Issuing Agency)
City Council Approval (if applAcable)(Attach Minute Entry):
ADB Approval (if applicable)(Attach Minute Entry):
Building Official Approval (if applicable): -64
Signature Date
Provision for Indemnity:
Terms and Provision of Performance Bond, if applicable:
kPERMIT AUTHORIZATION BY- /-'?Z73�6_4
SiqWa'ture
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PERMIT NO. Date Issued: 41211Y6 Permit Fee:
Remarks/Comments: 1-776
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CIT' OF EDMONDS SIDE 'EWER PERMIT
WATER -SEWER DEPARTMENT
PERMIT N9 5291
(Call 775-2525 for side sewer inspections BEFORE covering any Portion of the constructio
Inspection will be Provided within 24 n,)
0
hours after requat. NO Sat., Sun., or holiday Inspectl
ns.
ADDRESS LOCATION OF CONSTRUCTION.
(?.ICL� .................... . ................ d ................. ..........
PROPERTY LEGAL DESCRIPTION..
. ..........
. ..........................................
.................................................. . ...................... . ........................................................................ . .............. . .................................. . ..................................................
0.
---------------------------------------------------------------- OWNER AND/OR BUILDER... I . ........ .
........................................
CONTRACTOR'S NAME ADDRESS ............
...................................
Permission Is granted --- .................... for repair and/or connection of a side sewer to the city sanitary sewer
system in accordance, w ty of Edmonds ordinances.
STTENTION IS CALLED TO THE FOLLOWING:
NOTE No. I —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.
NOTE No. 2—All work performed in city right-of-way requires an Invasion of RJght-of-Way Permit obtainable from the City Engineer's office.
e
NOTE No. 3—Obtain full information r garding Ordinazice 11.16.030 and Regulations governing side sewers when you get permit.
must
NOTE No. 4—Top of side sewer have at least 30 inches coverage at Property line and 12 inches inside Property line; minimum grade of 2%. No bends in grade
sharper than % will be permitted.
NOTE No. 5---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.
NOTE No. S—It is unlawful to alter or do any other work than Is provided for in the permit, or to do any work on the maJn sewer or its appurtenances except
sert the pipe into the wye.
to in
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DISAPPROVED Date .. . ...... .......... BY ................ Date� BY ................ Date .............. BY
-- --------
--------- . ................... ................
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"PROVED 0 Date B
. .............
.. . .. . .......................................................................................
Remarks: ....... . ..................................
. .. . .........
............... ..........
.................. . ........
..............................................................................................
......................................
........................ . ........................................................................................ . .................................. . .......................................................
BOTH Permit Copies MUST Be Signed By Owner of Firm Performing Construction PRIOR To Request
For Inspection
I ....................................................................................... .... hereby certify that the side sewer installation constructed under this permit
(Owner of Contracting Firm Performing Construction)
(D-Winstalled in accordance with all governing ordinances of the City of Edmonds.
Datedthis ............... . ........... day of ........................................................... 19 .........
A-M I
Check BEFORE you dig for: Water Elt Gas Telephone 0,
Power Sewer Other 0 %t V
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WY, a
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The City of Edmonds
APPLICATION
for
SIDE SEWER PERMIT
NEW CONSTRUCTION E],
EASEMENT NO - ------------------ --------- ...............
REPAIRS F-1 LID NO. ..4LY'.--..ASMT. NO.
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OWNER -------------- ca ---------------------------------------------------------- CONTRACTOR ........
NO.
JOB ADDRESS
.......... LEGAL DESCRIPTION: LOT NO - ------------- <�� ------------------- BLOCK NO - ----- --5 ....................
------------------------------------------------------------------------------------ -----------------------------------------------------------------------------
NAME OF ADDITION ...........
Approved:
DATE..
............................... By ------------------------------------------------------------
n - AV
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