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18412 72ND AVE W
PE11ZM IT NO:, 9392-
C ity, of Edmonds,. (oh /of
Q'F"U QUIVU'D
"7c. 199-
Address of Construction: /841 12 V e_ MeI7..' LID #
Property Tax Account Parcel No. 4�17_5---WO-02000
Attach copies of all access and utility easements Verified and Approved b
Owner and/or Contractor* Pe*_r-rt4vxv�Ue_ ro)( `*N
Contractor Licen�e #: r r � S Building Permit A
,2"S--ingle Family
F� Multi -Family (No. of Units
Ej Commercial (No. of Units
n Public.
by 112
Invasion into City *Right -of Way: Yes
0
*RW Construction Permit #
Cross other "Private Property: 0 Yes N40
"Attach legal description and copy of recorded easement.
4 )-,� r - Ee�� Owner/Contractor
Owner or contractor signature and acknowledgement statement:
'B signing for this permit I certify that I have read the City's public handout entitled
y
ide Sewer Specifications, and shall comply with all City requirements outlined therein.
9 CALL DIAL -A -DIG (1-800-425-5555) BEFORE ANY EXCAVATION
.9 FOR INSPECTION CALL 425-771-0220 extension,99��&
24 HOUR NOTICE REOUIRED FOR ALL INSPECTION REOUESTS
Date
...................
... ........ .. .. ..
..... .....
FOR OFFICE USE ONLY . ......
. . ....... .. ..... .. . ... ...
Permit Fee $ 30 Repair Fee $ Issued By:
Trunk Charge $ Date Issued:
Assessment Fee $ Receipt No: /7-Oto V-
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 FEEMILL BE CHARGED.
Job Site Ready YES NO, Date: Initial..,
Partial Inspection: Date: Initial:
Partial Inspection: Date: Initial:
As' -built to Street File:
OVED: Date: nitialDYL—..
FINAL INSPECTION APPR
f,� PERMIT MUST'BE POSTED ON JOBSITE.t,
WhiteCopy: File, GreenCopy: Inspector BuffCopy: Applicant
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74' -61
C ITY OF EDMONDS SIDE SEWER AS -BUILT
ADDRESS
PERMIT
18412 72ND AVE, W.
NUMBER 9 3 9 2
HOMEOWNER
CONTRACTOR
xxxxxx
PERRINVILLE
DATE
04/25/01
DRAWN
BY L ABILA