19022 DELLWOOD DR.PDFIIIIIIIIIIIIII
10889
19022 DELLWOOD
DR
00
ADDRESS:
TAX ACCOUNTIPARCEL NUMBER:
BUILDING PERMIT (NEW STRUCTURE):
COVENANTS (RECORDED) FOR:
CRITICAL AREAS:
DISCRETIONARY PERMIT
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
PERMITS
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED:
SEWER LID FEE $:
SHORTPLAT
SIDE SEWER AS BUILT DATED:
SIDE SEWER PERMIT(S) #: A
GEOTECH REPORT DATED:
DETERMINATION: 0 Conditional Waiver F] Study Required 0 Waiver
LID #:
LOT: /f BLOCK:
STREET USE (ENCROACHMENT PERMIT #:*,da 1212MI (No d-)
FOR:&C,6
I
WATER METER TAP CARD DATED
LATEMP\DS'Ps\Fbrms\Strcet File Checklist.doc
APPLICATION
for LYNN PLANT
The City of Edmonds SEDE SEWER PERMIT EA EMENT No . ..........................................
:�/j� - 0<5 9! 0. (0- NEW CONSTRUCTION E] REPAIRS E] .4,1V -X.19
OWNER AAC ........ ................. ....................... CONTRACTOR ....... ........ PERMIT No.
e. ADDRESS . ........ P. .......... lot ... 0 ........ LEGAL DESCRIPTION: LOT No. -1.4 . . ............................. BLOCK No . ............................................
NAME OF ADDITION ..OA14 ... W.A ... d .... a ............. ............. .......................
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CITY OF EDMONDS DATE RECEIVED 17--2-
16COMMUNITY SERVICES DEPARO
_T
250 5th Ave N DATE ISSUED
771-3202
PERMIT NO.
APPLICATION FOR STREET USE PERMIT
Name of Applicant:
Mailing Address: W 0 0J, L>-y
Telephone Number: Date: L)
ke-
Description of Public Place or Portion thereof desired to be used: (exhibit
may be attached)-
k�& vt a e- S
Type -of Use desired to be made of Public Place: —h_,(e_Mg&e
V
iL.Iv.., . U
\JAk ko 0,01Cy\ �Q^ ".
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 th.is
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,
including 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, a.nd understands that all terms of that
Ordinance are incorporated herein as if set forth in full ao4his application
and permit therefore are subject to the terms of thal,"hap er f the Ed nds City
Code. �\ � n7
f/ I A -A / I-V-
Appl-fcadt's Signature
0
Date
City of Edmonds, Community Services Department
APPLICATION FOR STREET USE PERMIT - - Paqe 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 (i.f applAcable)(Attach Minute. Entry):
ADB Approval (if applicable)(Attach Minute Entry):
Building Official Approval (if applicable):
Signature
Provision for Indemnity:
Terms and Provision of Performance Bond, if applicable:
PERMIT AUTHORIZATION BY:
PERMIT NO.
RELEASED BY
Remarks/Comments:
FIRE DEPA RTMENT APPROVAL
SiqnAt-ure
Date Issued:
RECEIPT NO.
Da
Date
Permit Fee:',
BUILDING PERMIT #
DATE
POLICE DEPARTMENT APPROVAL DATE
ENGINEERING DEPARTMENT APPROVAL
,jg�� DATE a -// -f;7
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...;-CITY OVIDMONDS'
Can ]�Rosoect -.6-1107 when work
WATER-SEVVER'DEPARTBUDSIT
CMC: CENTER
is for, InspecUon. (No ftwpec-
uopj!�Sat"i' S'�.�r holidays.) NO. ..1584,
. .... .. :SIDE SEWER. -PERMIT..'
AbD 2 J)e d --- R . .......................
BESS ----- . ... -ve
--------------------------------------------------
OWNER ..... ......
--- S.ew-ar'..
................ - ------ --------- CTOR. .111
.....................
Perhijs4on. is
granted ... Xehr-Ual�y:_7 --------------- 3A.6-7, for .......
71: ...... da�ys, to REPAIR. or CONNECT a side sewer
with City'Sewers in aecordafi�e wltix,'a�pfibation o rij
It e and governing ordin=ce&
ATTENTION -IS CALLED
T0,,THE.F0LL0WING:
. NOTE'Noi I�Th6 owne�. of the, Z�Dl)efty.may obtai
-permit, to construct sewer inside property -line. A licen d,Side Sewer dantractor. must
se
b6 employed to construct sidi'sewer in -stnr'eaet �area. Do hot before- it has been: Inspect
cover any portion of 'se*ii ed.
No. ZQbtain full
Inf
prmation regarding 0 ingn -11.1&030 and Regula� Ons governing -side iewers when you get'perm t.
rd e
NOTE N . o. 3—Top. of. side sewer must have at least. 30k ��chcs coverage at property line and.12 inches Inside property line; minimum grade of 2%.
NO: bends, in grade sharper than'. % wi]174i� !permitted.
NOTE -No. 4--Trench�s in,street must be wite� settied.`�i�kn' a:' -surface; of street restored to original condi . tion. Contiactors hall 131 . e resPons ble for
-:failure due !'to, Improper work which may -,dei�l p within one year of 'completion.
NOTE No. '5--It ig� Unlawful. to alter or'do any. other is provided for in the permit, or to do ELnY* work on th�e main sewer or Its ap-
"Purteniances,exeelyt'to insert the Pipe into tlie:.x I ye.