20620 78TH PL W.PDFlill 11111111
6773
20620 78TH PL W
NOTICE:
No warranty of accuracy.
The information shown on the attached
map(s) was compiled for use by the City of
Edmonds, its Employees and Consultants.
The City of Edmonds does not warrant the
accuracy of anything set for - th on these
map(s). Any person or entity reque sting a
copy should conduct an independent
inquiry regarding the information shown on
the map(s), including, but not limited to,
the location of any sewer stub shown. Such
sewer stubs may or may not exist and may
or may not exist at the location shown.
Neither the City of Edmonds nor its
employees or officers 'sha H be liab-le for the
information given on this map(s), nor for
any one representation provided based
upon said map(s).
" CITY OF EDMONDS
CIVIC CENTER — WATER -SEWER DEPARTMENT Call PROSPect 6-1107 when w ork
is ready for inspection. (No lospee-
SIDESEWER PERMIT lions S%turftY, Sunday or holl"".) N? 2010
211 22nd Avenue North
ADDRESS........................... . ...................
OWNER ........... Gerald W. Lambe
............................................................................. .... CONTRACTOR ---------- 01YI�P-i-C ... Ylew --- Plumhiii& .........
April 12 67
Permission is granted ................ .................. I ......... 19 -------- , for ------------------------ days to REPAIR or CONNECT a side sewer
with City Sewers in accordance with application on file and governing ordinances.
ATTENTION IS CALLED TO THE FOLLOWING:
NOTE No. 1—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—Obtain full Information regarding Ordinance 11.16.030 and Regulations governing side sewers when you get permit.
NOTE No. 3—Top of side sewer must 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.
'E No. 4—Trenches In street must be water settled and surface of street restored to original conditio ntm ors all be ible for
failure due to Improper work which may develop within one year of completion. n Co ct sh respons
ts appur-
tenances except to Insert the pipe Into the wye
NOTE No. 5—It Is unlawful to alter or do any other work than is provided for in the permit, or to do any work on the main sewer or I
APPLICATION FEYKN PLANT
for
The City of Edmonds ^-rn SIDE SEWER PERMIT
rjFFNEW CONSTRUCTION REPAIRS EASEMENT No . ..........................................
OWNER ..... �kv . . ....... . .......... CONTRACTOR -Z� ..... ... ................................... .... ' PERMIT No.
ADDRESS .......................................... ...... ................. —) LEGAL DESCRIPTION: LOT No . .........
........... — ........ .................................... BLOCK No . ............................................
&Z 'rAlg- NAME OF ADDITION ..... ,7— ........ ................ =4..;2 ..............................
..... .....
V'
4PPROVED""�
AP"gj*jt��
All,
Approved:
DATE ...... By
Y................. I ........... a ...............................
vz — 7, 7,74-�
% . _-.16
'I C. 1 -6 -) -
Address of
PERMIT NO: 9830
City of Edmo'nd&
PERMIT EXPIRES //A�``�/A`_.
SIDE SEWER PERMIT
ristruction: A06);4) - -1 e --::,4 LID #
Property Tax Account Parcel No.m�w 1100 0001ho
Attach copies of al . I access and utility easements V�iifieddand -Approved b
COwner and/or Contractor: -ha rce,,.i L - F-6SA-f
6(oqs
Contractor License v"_ Building Permit*., QD0 �3
Single Family
Multi -Family (No. of .6nits
El Commercial (No. of Units
F� Public
Invasion,int6 City �'Right-of W�y: El Ves Oro
*RW Construction Permit
Cross other,"Private Property: 1�es No
j
**Attac legal desc I ription and copy of recorded easement.
6goAld.— OC Owner/C'ontfact6r 6
Owner or cont(p6or�slgiiiture and acknowledgement, statern'e'nt: Da,fe
By signing for this,permit I certify that I have read the Cit "s- goblic han'dout entitled
p
yj
Side Sewer Specifications, and shall comply with all City retl�irements,, outlined therein.
A.
2'..CALL DIAL -A -DIG (1-800-42—,L BEFORE ANY EXCAVATION.2
9� FOR INSPECTION CALL 425-771-0220 extensionm
24 HOUR NOTICE REOUIRED FOR ALL INSPECTION REOUESTS',
NOTE: IF JOB SITE IS NOTREADY FOR INSPECTION WHEN
INSPECTORARRIVES A $45 RE.INSPECTION F . EE WILL BE CHARGED.
Job. Site Ready YES NO Date: Initial:
Partial Inspection: Olt to bOA-11 ge �v i1he Ar yxid "'h& -4eed 7�9 Dat*6t'.A ?h 04 Initial:
Partial Inspection: )hsbUJ- Oj&Pold. P_cd� /,On( h/mdjv/V�PaW Initial:
FINAL INSPECTION APPROVED: Date: --0-112,[04 Initial- As -built to Street File:
1,� PERMIT MUST BE -POSTED ON -JOB SITEn,
WhiteCopy: File Green Cop�.: Inspector 'BuffCopy: Applicant
L;temp;bldg,forms;sspermitjlg4/00
ABS 2' OUI
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0
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I,, -
CITY OF EDMONDS SIDE SEWER AS- BUILT I
ADDRESS
2.0620 - 78th Mace
HOMEOWNER CONTRACTOR
Darcey L, Foster
DATE DRAWN
3-23-2004BY K, Haney
West
PERMIT
NO. 9830
SCALE
NTS
CONCRETE PIPE DETAIL
ROAD BED '�i- ";" >'
)��-10'- PEA GRAVEL BASE
WITH NATIVE SOIL
5/9" FOR FIIL AROUND PIPE
LOT J
701-0'
r- VV/-kl I
1 1
70' APPDX. NEW 12" CONCRET PIPE
LOT A
UNDERGROUND CONCRETE DR INAGE PIPE
NOT TO SCALE
LOT I
; -- () 11
IVE A
LOT G
64'-00
70'--0'
I DRIVE WAYI
\-NEW CATCH I BASIN 70' APPDX. NEW 12" CONCR
TYPR # 1
WITH CAST IRON FRAME/GRATE
60' APPDX. NEW 12" CONCRET PIPE
LOT B LOT C
a z
lVE WA' (
PIPE
CONCRETE PIPE DETAIL
ROAD BED
V�����ASE
WITH NATIVE SOIL
5/9" FOR FIIL AROUND PIPE
LOT J
"DRIVE WAY
70' APPDX. NEW 12" CONCRET PIPE
LOT -A
LOT I
IVE W# LOT G
4'- 0'
DRIVE WAYI
\-NEW CATCH BASIN 70' APPDX. NEW 12" CONCRE
TYPR # 1
WITH CAST IRON FRAME/GRATE
60' APPDX. NEW 12" CONCRET PIPE
LOT B LOT C
o(,o a,? - -7F #0, 0. . N, .
UNDERGROUND CONCRETE DRAINAGE PIPE
NOT TO SCALE
ZzI,
!IVE
PIPE
APPROVED AS NOTED
BY ENGINEERING
Date:
HEIGHT CALCS,
A = +99
B= +99.5
C = +99.25
1) = +99
AVG GRADE = 99.1
PROP. HEIGHT 113
MAX. ALLOWED 124.1
+98.5'
0
06
060 Set
z
It,
u-
z
r-
IMPERVIOUS SURFACE CALC5
EXIST'& ROOF OUTLINE 1647 S—.1
EXIST'& DRIVEWAY 474 S.F.
EXIST'G PATIO 120 S.F.
PROPOSED ADDITION 896 S.F.
99.36'
10,-�RAINAGE EASEMENT
A
E>(IST:
CONC. :
-Tl� PATIOi
EROSION CONTRq—ai��)axw
im I PROPOSED 720 S.F. AUDIT]
LO
0
MASTER
r
BEDROOM
WS
MA S CLO
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ice
U) En
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TO ONNECT T :EXIST. SYST.
z fff, 77.
fu SUNROOM
w-
PROPOSED ADDITION FOP
r)AP,CEY F05TEP- LL-
20621 78TH PL W V...
EI)MON05 WA 9802W
REFERENCE ELEV.
26- EXIST-6 215 TOP OF CS = 100'
A It I I--,
N890 41, 101, W I �� I
w EXIST 0-S7.
z &PAVEL
w YARD
EXIST
499 �5 C01TNC.I
I ' I
EXIST'& 3 DRIVE
GARAGE
FOP,
0
LO i
100
00
EXIST'&
ui
SFR
3
10
NA 5..,
0 .......................... 0^ ......
E>(ISTING WOOD FENCE X
N890 41' 10 W 99.33'
22' 30' ADDITION I
Lecial bescription:
Jackson Park BLK 000 D-00 LOT I
Tax Parcel I.D. No.
00 4811 000 001 00
Lot Area 8742 S.F.
Lot Coverage Existi 1469 S.F. (16.8%)
Lot Coverage Propose9d 2189 S.F. (25%)
Lot Slope < 2%
u
+99.2
0
ETEP UTILITY
+100 POLE
North APPROVED BY PLANMNG
9141-13
ZON
FPONrT5ET13ACK' -20'
Scale
ill SIDE SETBACK 75
20 1
REAR SETBACK 15
LOT L�UN�� MUST
BE IN PLACE AT TIME OF
r�- e-� 1 FN P r� A 7 q n N1, I 1h, �-,!7 r7, T I r)\ I
PLANNING DATA
NAME: Lz6c% L-, 4- f/-e� DATE: e-21 4/ -3
SITE ADDRESS�' 2-14, 2, 79- 121, -.PLAN CHK#:—O 3 - 3Tg
PROJECT DESCRIPTION: 2- IA,-�., j A.,4,
REDUCED SITE PLAN PROVIDED?: Q / No)
MAP PAGE: 2--�o b CORNER LOT: (Yes FLAG LOT: ffes /Vo
ZONING: S -9 CRITICAL AREAS DETERMINATION #: 03 -S&
LJ Study Required:
@CWWalver
JConditional Waive
SEPA DETERMINATION:
Ll Fee
Ll Checklist
LJ APO list w/ notarized form
LJ (Needed for 500 cubic yards of grading, Shoreline Area-* site within 200 ft. of Puget Sound or Lake Ballinger)
U'Exempt
SETBACKS:
Reciuired Setbacks:
Street: 2-5' Left Side:-7, 5 Right Side: 71 Rear: 1E,
Actual Setbacks: f� P.&o,��
Street: q ?, Left Side:__ 327,5�kight Side: 3-2' Rear: Z2
Street map checked for additional setback required? (Yes / No / DNLk)
L3 DETACHED STRUCTURES:
Ll ROCKERIES:
LJ FENCES/TRELLISES:
Ll BAY WINDOWS / PROJECTING MODULATION:
Ll STAIRS/ DECKS: 9 '-AD - 611�fhl:� 1, -.4-f -%
PARKING: Required: 2� _Actual: ( " +- 1
LOT AREA: 19-3 1 ff -- �,739,4
LOT CO ERAGE: 1647o-g9j, Z,';'
Calculations: -73e, 4
BUILDING HEIGHT:
Datum Point: �b a —Datum Elevation: /60
Maximum Aflowed: `2- Actual Height:
A.D.U. CREATED?: �/Yes)
SUBDIVISION:
LEGAL NONCONFORMING LAND USE DETERMINATION ISSUED: (Yes
OTHER:
Plan Review By:—
V
NewBPP1anningDataForrn.D0C
Critical Areas Checklist
Site Informatibn (soils/t 6p'o
graphy/hydrology/ vegetation)
1. Site Address/ Location: o�D'� ;) 0` _� S
2.
3.
4.
5.
CA File No:
Property Tax. Account Number: le�57&�f
Appr ioxin-tate Site Size (acres or square feet): i az-, (0-
Is IM6'site currefitly'.develo�60 yes; 'no'.
If yeg;how is site developed? t4�ea, I-cfeVA -Ft
'hy. Chec . -all that apply.
Desm,"be. the general site topograo, k
Flat less than 5-feet�elev`ation chaniie over entire site.
Rolling: slopes on site %enerally less than 15% (a vertical rise of 10-feet over a horizontal
distanced 66-feet).
Hilly: slopes present;,on site of more than 15% and less than 30% (a vertical rise of 104eet
over a horizontO distance of 33 to 66-feet).
'Steep: grades of greater than 30%.preseni'on site (a vertical rise of 10-feet over a horizontal
distance, of lessithan �Meet).
Other (please describe):
6.1 Site contains areas of year-round standing water: C�0 Approx. Depth:
7. Site contains areas.of seasonal standing water: f) Approx. Depth:
What season(s) of the ye air?
8.1-: Site is in the flo6dway 00 floodplain.
of a water course.
9- Site�,contains a &eek or an area x4here water flows across the grounds surface? Flows are year-round?
0.) Flows.are',seasonal? - (What time of year?
10. Site U primarily: forested meadow ;shrubs mixed
urban, landscaped (lawn, shrubs etc)
11. Obvious wetland'Is present on site:
I .
J faknoq.k. o-vbt64cen
I I
—For City Staff, Use Only
1. Plan Check Number,. if a pplicable?
�� 2 _Si
is, Zoned?
3. SCS mapped soil type(s)? C)"X_nov�, (2CYYY-%.4j-j 0 a IL J
4.
�9D -$�
5. Site� 'within design a-ted. earth subsidefic ar area?'�,164- 4Q 0r4
e landslide haz d
1-4, n n A- 1) k
'DETERMINATION
! ; : IV— - � 1. . - , 1, : , ,
Cri�cat Aieis CfieA'I_Iit.doc/4.&!2003
WArVER
ate:,
'V. Jb7
City of Edw�o' fid's
Development,Services' Depatim6rit
PlannftlgL Division
Phone: 425.771.0220
Fax: '425.771'.0221
The Critical Areas Checklist contained on this form is to
be filled out by any person preparing a Development
Permit Application for the City of Edmonds prior to
his/her submittal of the application to the City.
The purpose of the Checklist is to enable City staff to
determine whether any potential Critical Areas are, or
may be, present on the subject property. The information
needed to complete the Checklist should be easily
available from observations of the site or data available at
City Hall (Critical areas inventories, maps, or soil
surveys).
,:Date' Received:
#:
1366
Ci!�, eip
Cotical Areas File #-.
Critical, Areas Chdckl1st.Fe6-- 'Ji:_�:4136106 -
DAt6 Mailed to'App!i' '; :' -; .;, �.' .� ' � I
cant;.
A property,owner, or his/her authorized rep.pppentative,
must fill out the checl-dist,'sign and date'it, and!§ubmit it
to -the City. The City will review'ifie -checklist, �mAke a
precursory site visit, and, make a determination of the
subsequent steps necessary to complete a development
permit application.
Please submit a vicinity map, along with the signed copy
of this form to assist City staff in fitidingi and locating the
specific piece of property described on this form. In
addition, the applicant shall include other pertinent
information (e.g. site plan, topography map, etc.) or
studies in conjunction with this Checklist to assistant staff
in completing their prelimir4ry assessment of the site.
The u ' ridersigned applicant, and his/her/its heirs, and assigns, -in consideration on the processing of the -application agrees
to release, inderrmify, defend and hold the City of Edmonds harmless from a�ny and all damages,. ihclud'm*g reasonable
attorney's fees, arising from any action or infraction -based in whole or part upon false, misleading, in'a6curate or
incomplete information furnished by the applicant, his/her/its agents or employees.
By my signature, I certify that the information and exhibits herewith submitted are true and correct to the best of my
knowledge and that I am authorized to file this application on the behalf of the owner as listed below.
SIGNATURE OF APPLicANT/AGENT
DATE
Property Owner's Authorization
By my signature, I certify that I have authorized the above Applicant/Agent to apply for the subject larid use a pplicati6n,
and grant my permission for the public officials and the staff of the City of Edmonds to enter the subject prop .,
efty for.the
purposes of inspection and pefting attendant to this application.
SIGNATURE OF OWNER kA4&_1_ X_,_Te� DATE
Owner/Applicant:
:�)01S_ QR\4 I- � Fo&+�c
Name I
LD
0 �p a (D - -1,2 �,)_ ,
Street Address
City State zip
Applicant Representative:
Name
Street Address
city State Zip
Telephone: 1A -c),S - (v (0 Telephone:
Email address (optional): d-6),S-ff r -k>JJ n�e( r)f+,yiErnail Address (optional) -
Critical Areas Check] ist.doc/4.22.2003
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEMAME OF BUSINESS
CL r_ C'.
MAILING ADDRESS
/1 2D6 -7 g L
_,c
CITY ZIP TELEPHONE
G_�drn o nAA 9;roa0Ljg15-(o73-&
NAME
C�4 can C-)
PERMIT EXPIRES
USE PERMIT
ZONE
NUMBER
JOB
ADDRESS ll��
SUITE/APT#
k)
PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved 13
AW Pernilt Required
Street Use Peffnil RoWd
EXISTING — PROPOSED
Inspection Required
Sidewalk Required 13
REQUIRED DEDICATION— Fr
Underground
Wiring required
METER SIZE
LINE SIZE
NO. OF FIX`rURES
PRV REQUIRED
YE NO 13
SY
rE
Ul
REMARKS
Z
I
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION
CONTROL/DRAINAGE
(5
A
4r I f-t hi
z
LU
CITY ZIP ITELEPHONE
ail! I I hA
E\)fff__4
-1(1z-%i
T lrmtmkvr� (AlBOAt- 1-6all-ki-
NAME
CBL #
ENGINEERING REVIEWED BY DATE
0-
lE )*DFiESS
0
FIRE, REVIEWED BY DATE
CITY ZIP
TELEPHONE
0
VARIANCE OR
�,S,PRELINE
H OR ADB�
INSPECTION
��REO'D
BON D
POSTED
STATE LICENSE NUMBER EXPIRATION DATE
CHECKED BY,
YES IWO
$
SEPA REVIEW,
COMPLETE' �EXEMPT'�,
',SIGN AREA',-'
:,�ALL6WEI51." 'PROPOSED
HEIGHT
ALLOWED PR POSED
PROPERTY TAX ACCOUNT PARCEL No.
004-1? 11 001,101, 0 .
I
11.1
2-5 1 )4
1)
EXP, ".
� "', � � %
NEW 0, ESID-ENTIAL PLUMBING MECH
LOT,COVIERAGE,''.-
ALLOWED,
_�RE661REIJ*S ET BACK
,, S (FT.),
:PROPOSED SETBACKS (Fr.)
FRONT IJR SIDE REAR
_�:,PAbpb§`ED'1'
0
'two.
COMPLIANCE OR.,
ADDITION C MMERCLAL
13 CHAA66 OF USE
7
F
z
z
PARKING L'L6T4REA'
R E0`0 PROVIDED
.11.
'PLANNINGREVI EWED BY DATE
1
REMODEL �., '', MULTIFAMILY SIGN
5
0,
FENCE,
REPAIR El
DS Fr)
REMARKS
OTHIER:,:,
DEMOLISH TANK
GARAGE Ey RETAINING WALL',:" RE SPRINKLER
:R6CKEFiY.:,:
z CARPORT FIRE ALARM
(TYPE OF USE, BUSINESS OR . PTFVrrY)'E I XPIjPN.
4-mm<�, / !�2 11�7FO--._ / I
CHECKED BY
TYPE OF CONSTRUCTION
I I V-Al
CODE
OCCUPANT_
GROUP ):<3
NUMBER
OF
NUMBER OF
DWELLING
1
CRITICAL U I
AREAS
SPECIAL INSPECTION JAREA
OCCUPANT
01 1
0 STORIES
UNITS
NUMBER
REQUIRED [:] YES. I
—7--s—
7-ZV
LOAD
z
DE BE DONE
,ff!51�rRK TO
Red r 1) 10 fVN1
REMARKS
PROGRESS IN6PECTIONSPER UBC108/FINAL INSPECTION REO'D
C.)v _np-A
j!x L N -k ti Q %Rnr\jW
kesi!&Aroay,�
VAL�ATION
$
D eiscription
'�'FEE
Description
FEE
30')("
Plan k
Chec
yt,)V.
State Surcharge
HgT SOURCE GLAZING % jLOTjSLOPE %
Zuilding.fprrinit City Surcharge
L%
PL,AN CHECK NO: VESTED DATE
'Plumbing.
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
It BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
2 TC.) WILL REQUIRE
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, E
SEPARATE PERMISSION.
Engr. Review
lu PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT: I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspection it=:I-)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
Fire Review Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection Receipt III
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY: WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
Landscapelnsp. Total Amt. Due 4
0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION!
Recording Fee Receipt # -00
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
This application Is not a permit until signed by the
CALL
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
Building Official or his/her Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION receipt Is acknoWledged In space provided.
WORKMEN'TPOIPLIA(SATION INSURANCE AND RCW 18.27.
U
OFFICIALS SIGNATURE DATE
AGTE DATE SIGNED
(425)
RE B
ENT"
Off 1333
7—Aall4A
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 14( j
-_ Pip],
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- 64 1
ORIGINAL - FILE - YELLOW - INSPEKTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
PINK -OWNER - GOLD -ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
XW
city of Edmonds: PermitNo:
RIGHT-OF-WAY CONSTRUCTION PERMIT. lssuelbate��`
Q 0 - -7 E-L\ PL UJ
A. Address or Vicinity of Cionitruction: o� 06d-JAA U0_016
B. Type of Wor . k (be specific): ) In Ni a c A, oe nr fee-+
_:m to\,Jefll�_ V121. ^A
16', r) D'i rx -6_-�,N6 r) r, QO A W'I OVA) i nAl� MrA'\ Q AM
t"It'V.10'r Aklor �...YaA .,rrx\je-\ nAA -�Ikk rk1'%rA-,
C. -Contractor:L.Z:,WjVr.
(Mailing AddreEs:110931—
tate License )&rr-ed
D. Building Permit # (if applicable):
E.
r-l' Commercial
E] Multi -Family
NSPECTOR:
El Sub.divi'siiod
Single Family
�,(' C_k
Liability Insurance: Bond:
Side Sewer Permit (if applicable):
EUC UD, V_ER
O'City Pro�e 7rdZC
Other
PSE, AT.& T, OVWD)
F. PAVEMENT CUT: YES _%�'DdNO G. lZ U X
CONCRETE CUT: El YES NO
AN'LICANTTO IZEAI) AN[) SIGN
INDEMNITY. Applicant understands -by signa re t, this a lication helshe holds the City'of Edmonds harmless ftom
r , p
er
_iSA e
'any, I �cvpiion w o er, for seen or unforeseen, that may* be made against the. City of
in kind'orlides 7\W1
juries, damages or claims of
Edmonds or any of its departments or employees, in ut no ZLmjJ)ed to the de
fense of any legal proceedings including defi�ense
cbsts and attorneyfees! by reason ofgranting -this perm
TIfE, CONTRACTOR IS RESPONSIBLE FOR ORK A TERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL
W
INSPECTION,AND ACCEPTANCE OFTHE VO TED RESTORATION FEES 97LL BE HELD UNTIL THE FINAL STREET PATCH IS
T
I
IM
COMPLETED BY. CITY FORCES, AT WHICH TOR CREDIT 07LL BE PROCESSED FOR ISSUANCE TO THE APPLICANT
'd public safety y
Traffic'�ontrol an all be in accordance with City regulations as rOquired.�b Ahe C.ity Engineer. Every
flagger must be 'trained as re � ired by (WAC) 296-155-305 and must 'have.'certification verifying completion of the.
required.training in their pos ssion.
Restoration, is, to be in accirdance with. -City codes. . All street-cu,t -trench work shall be.patched with asphalt*or City
ap -NO EXCEPTIONS.
proved, material prio5oto the end of the workday
Three sets of construe ion drawings of proposed work are required with the permit application.
p
LL DIAL -A -DIG (1-800-424-5555) PRIOR TO BEGINNING WORK
IMAVEREAD 'E,4BO VESTA TEMENTS�AND UNDERSTAND THE PERMIT REQUIREMENTS AND A CKNOAViED�E .7
T
THA' 7, 1 MUST ?AKETHE PfNK COPY OF MWfERJ�IIT A VAILABLE ON SITE A T ALL. TIMES FOR INSPECTIONS
_ex/
SignatuVre.4A,r L Date:
(contractor ortkgent)
Approved by: "Ve
Time'Authorized:. Void After.
Special'Conditions:
fro
1A
CITY USE ONLY
Right-of-way Fee: 1670
Di sruption Fee/Fund 111:
Restoration Fee:,
Total Fee:
-ReceipCNoi
".--o"l-s-sued bv*,
UPON COMPLETION OF PERMITTED WORK9 AN ENGINEERING FINAL
INSPECTION1S REQUIRED PER CHAPTER 18.00 OF THE EDMONDS
COMMUNITYDEVELOPMENT'CODE (Phone 425-771-0220'Ext. 1326)
FINAL APPROVAL OF PERMITTED,WORK. DATE:
In.�Pector's Signature
'For inspection requirements see Engineering Inspection Information handout.
NO WOIZK SHALI. 13ECIN 11MOIZ TO 111ERNirr ISStJANCE
DAMy Documents\Forms\Engnmg\ROWpermit_.doc
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