19021 DELLWOOD DR.PDF1111111111 lill
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19021 DELLWOOD
DR
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601
TAX ACCOUNT/PNRCEL NUMBER:V[�C0006,2&np
BUILDING PERMIT (NEW
COVENANTS (RECORDED) FOR:
CRITICAL AREAS:
DISCRETIONARY PERMIT
DRAINAGE PLAN DA
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
PERMITS (OTHER):
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED:
SEWER LID FEE
SHORTPLAT
SIDE SEWER AS BUILT DATED: . 9 leo
SIDE SEWER PERMIT(S) #: zj,-7
T- I
GEOTECH REPORT DATED:
STREET USE ENCROACHMENT PERMIT
FOR:
WATER METER TAP CARD DATED
DETERMINATION: E] Conditional Waiver E] Study Required F] Waiver
LID #:-&�
LOT: ZO BLOCK:
L\TEMP\DS'Ps\Fbmis\Street File Checklist.doc
The City of Edmonds
APPLICATION
for
S11DE SEWER PERNaT
NEW CONSTRUCTIONK REPAIRS C]
LV-%`.k P-iA!'4'T
EASEMENT No . ..........................................
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OWNER ....... tr��.�L—.'i:_r� .........
........................................ CONTRACTOR ........ ............................... PERMIT No
ADDRESS ..... ............. ovezl' ........ LEGAL DESCRIPTION: LOT No . ............ a;�7 !�� ...................... BLOCK No . ............................................
NAME OF ADDITION ......................
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Approved:
DATE ........ rr�.. Z ..........
.............
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City. of Edmon#
RIGHT-OF-WAV� CONSTRUCTION
ERMITPermit Number. C15,^ 03
81HEET FILL
Issue Date
A. Address or Vicinity of Construction: 19021 Del 1 wood Dr '
13. Type of Work (be specific): Replace 2 depreciated 40' poles with 45'
poles 731' deeo�.
C.'.Contractor: _�nnhnmish County PLID No. 1
MailingAddress: P.O. Box 1107,
State License #:
D. Building Permit # (if applicable):
E. [-] Commercial - El Subdivision
E] Multi -Family E] Single Family
INSPECTOR:
Contact: J'P-rry 171kington
Phone: (206)347-4414
Liability Insurance: _ Bond: $
Side Sewer Permit # (if applicable):
El City Project Ig Utility (PUD, GTE, VING, CABLE,'WATER)
FJ Other
INSPECTOR: Lo-J,;�C,31A
F. Pavement or Concrete Cut : 0 Yes KINo G. Size of Cut:
H. Chargq�,$
APPLICANT TO READ AND
t
INDEMNITY. Applicant understands and by his signature to this application, agre to h?ld the Citj, ofEdmoridg harmless from injuries, damages, or
claims of any kind or description whatsoever, foreseen or unforeseen, t ')against the City of Edmonds or an)6;Li1%5cfrt7ents or
employees, including or not limited to the defense of any legalproceedings including defense costs, . and attorney fees ;y Zonof n hi8permit.
THE CONTRACTOR is RESPONSIBLE FOR WORKMANSHIP AND MATERI41s"Fd�-AIPERIOD OF ONE YEHR F&LOAAW THE FINAL
INSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREET PATCH
IS COMPLETED BY CITY FORCES, AT WHICH TIMEA DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THEAPPLICANT.
Construction drawing of proposed work required with permit application.
A 24 hour notice is required for inspection; Please call the Engineering Division, 771-022 0.
Work and material is to be inspected during progress -and at completion.
Restoration is to be in accordance with City Codes.
Street shall be kept clean at all times.
Traffic Control and Public Safety shall be in accordance with City regulations as required by the City Engineer.
All street cut ditches shall be patched with asphalt or City approved material prior to the end of the working day;
NO EXCEPTIONS.
Ihave read the above statements and understand thepermit requirements and thepink copyof thepermit will be
available on . e at all times or,iospectio purposes.
Signaturz=:= Date: 4/12/95
ftonir—actor of1gent)
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
vwxv .. %11L J
�APPROVED BY:
TIME AUTHORIZED: VOID, AFTER EA rL— DAYS
SPECIAL CONDITIONS: VA
COMMENTS:
DATE:.
RIGHT OF WAY DEPOSIT
DISRUPTION FEE/FUND III:
RESTORATION FEE: 7
PERMIT ]FEE:
TOTAL FEE:
RECEIPT FEE: -
ISSUE'D BY:
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Eng. Div. 1994
FIELD INSPECTION NOTES
Comments:.
Diagram.:
(Fund 111 - Route copy to' Street Dept.)
CONTRACTOR CALLED FOR INSPECTION El YES 0 NO
Partial Work Inspection by P.W.:
Work Disapproved By: Date:
FINAL APPROVAL BY: Date:
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.11--l'.. .-I VUbLIC UTILITY DISTRICT NO.1 OF SNOHOMISH COUNTY e'�5r, eer,�W71--9
1476 Rev. 7/87
LOCATION
POLE NO. 1/4 _/fT Z7 R 4 DATE 9 W. 0. NO. _A52!570�10 3
ENCINEER,-/, OWG_ NO. /� A�7 -15
REASON FOR WORK
DRAFTER e,-Z�le,' U. G. N 0.
SCALE
DATE PRINTJP
DATE WORK COMPLETED APPROVED VX 3 1 10
FOREMAN ENVIRONMENTAL ANALYSIS I
I 1 0 EXEMPT 0 NOT EXEMPT SUBSTATION
FE S F\ Q U o YES
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RE�
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EE_ S FOREIGN CONTACTS
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INDEX I POLES I I P LAT
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UTILITY DISTRICT NOA OF SNOHOMISH COUNTY
1476 Rev. 7/87
LOCATION lffllf
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D WG. NO. ?F5
REASON FOR WORK ENCINEER,�_/
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DATE WORK COMPLETED APPROVED %V 3 1 'Yb 10
FOREMAN ENVIRONMENTAL ANALYSIS I - -
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MISCEL NEOUS FEES TAKE OFF POLE
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#
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ECEIPT# C-MAPi ri_
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