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17820 69TH AVE W
ADDRESS: slap Lk)
TAX ACCOUNT/PARCEL NUMBER: coo oc-) os
BUILDING PERMIT (NEW STRUCTURE):
COVENANTS (RECORDED) FOR -
CRITICAL AREAS:
DISCRETIONARY PERMIT
DRAINAGE PLAN DA:
PARKING AGREEMENTS DN
EASEMENT(S) RECORDED FOR:
PERMITS (OTHER):
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED:
DETERMINATION: E]Conditional Waiver 0 Study Required 0 Waiver
SEWER LID FEE $: LID #: C>)—
SHORT PLAT FILE: LOT: BLOCK:
SIDE SEWER AS BUILT DATED:_ 6/naZ21
SIDE SEWER PERMIT(S).#: C14 a
GEOTECH REPORT DATED:
STREET USE / ENCROACHMENT PERMIT
FOR:
WATER METER TAP CARD DATED:
LATEMP\DSrs\Fo=\Street File Checklistdoc
7 �,
"TERMIT NO: 94.18.
City of B
IT EXPIRES
SIDE SEWER TERMFRAN� Oopm
Ij LID #
;truction: oai;X7-)
Property Tax Account Parcel No. U -b -IF UQ U - L2 I I (j U U 12.
Attach copies of all'access and utility easements Verified and Approved by
Owner and/or Contractor: r, t'q 4- * Ache-, z"inc ts C,
Contractor License #:
4_SingleFami*1y
Multi -Family (No. of Units'
F] Comm' ertial (No. of Units.
�17c. 1 g9v
Address of
i,rding Permit #: -
Invasion into City *Right -of Way: 0 Yes Eglxo
*RW Construction Permit
Cross other "Private Property: 0 Yes, [21No
Lj Public ttach legal description and copy or recorded easement.
dr, Owner/Contractor
signature an&acknowledgement statement:
.Owner of contractor.
By signing for this permit I certifythat I have read the City's public handout entitled'
ide Sewer Specifications, and shall comply with all City requirements outlined therein
Date
9 CALL DIAL -A -DIG (1-800-425-5555) BEFORE ANY EXCAVATION 2
2:4 FOR INSPECTION CALL 425-771-0220 extension.329
24 HOUR NOTICE REOUIRED FOR ALL INSPECTION REOUESTS
Assessment Fee Receipt No:
City Permit Surcharge Fee $5.00 Total Fees Paid $
NOTE: IF JOB SITE IS. NOT READY FOR INSPECTION WHEN
INSPECTOR ARRIVES A $45 RE -INSPECTION FEE WILL BE CHAR
QED.
Job Site Read Initial:
y YES' N 0, Date:
Partial Inspection: Date: —initial!
Partial Inspection: Date: Initial:
As* -built to. Street File
-FINAL INSPECTION APPROVED: Date: Initial: El
1,� PERMIT MUST BE POSTED ON JOB SITE'M.
White Copy: File Green Copy: inspector Buff Copy: Applicant
L;iemp;bldg:,form'ssspe.rmitjli4/00
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