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21116 PIONEER
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TAX ACCOUNT/PARCEL NUMBER: 170
BUILDING PERMIT (NEW STRUCTURE):
COVENANTS (RECORDED) FOR:
CRITICAL AREAS:
DISCRETIONARY PERMIT
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED
PERMITS (OTHER):
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED:
SEWER LID FEE $:
SHORT PLAT FILE:
SIDE SEWER AS BUILT DATED:
SIDE SEWER PERMIT(S) #:
GEOTECH REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
WATER METER TAP CARD DATED:
OTHER:-.
- g& (
DETERMINATION: E] Conditional Waiver 0 Study Required 0 Waiver
LID #: 1 (0 1
1�
LOT: I BLOCK:
LATEMP\DSTs\Fomis\Street File Checklist.doe
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CITY of EDMQODS RECEIVEQ
For Inspection Call 771-3202 MAR 1986
PrLIC WORKS
Address of Construction: OW/ 6 1 0 V-,e e r
S E SEWER PERIVI.IT
ePERMIT NO.
EDMONDS
TREATMENT 'PLANT
Property Legal Description (Include all easements): '-47 3
Owner and/or Builder:
Contractor & License No:
Single Family Residence
Mul ti-Family
Commercial
0-S
1A
(No. of Units
(No.. of fixture Units
IQ ki I m 0Z 4 A3 0 V /3 (?_
Invasion into City Right -of -Way: No Yes- (If Yes, Right -,of -Way
Construction Permit required. Call One -Call -Center (1-800-424-5555) before any
excavation.)..
Cross -other Private Property: No '-- Yes � (If Yes, easement required,
attach legal description and county -easement number.)
PLEASE READ THE ITEMS LISTED ON THE BACK
62, a � - (. - &,6
I certify that I have read and shall comply Date
with the items listed on the back.
Permit Fee:
Issued By:
Trunk Charge:_7��
Date Issued:
Assessment Fee:
Rece,ipt No.:
1.200
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Partial Inspection:
Comments Date Initial
Final Inspection Approved: 3-77-86
Date Tnitia INSP _Bb 1306 13E113'TLCR
Rejected:
Reason Date Initial
"'PERMIT MUST BE POSTED ON JOB SITE
White Copy File Green Copy Inspector Buff Copy Applicant
Side Sewer Drawing
The City of Edmonds EASEMENT NO . .............. ..........................
NEW CONSTRUCTION REPAIRS F� LID NO. .1(01 ----- - ASMT. NO . ..................
OWNER .................................................. --------------------------------------------- CONTRACTOR ----- C-OMSM/ -AKI-314.. PERMIT NO.
JOB ADDRESS .?,AAl-(o ...... Rin-NeAFk--� ------------------- LEGAL DESCRIPTION: LOT NO. ---------------------------- BLOCK NO - -- --------- EMMOMDS...
TREATMENT PLANT
------------------------------------------------------------- ........................................ -------------------------- --------------------------------
NAME OF ADDITION eSPI-R�hM.0 ------ C�S:T 5k .................................... ----------------------
P, (ON cc: T..�
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Approved:
DATEI".115j.0-2 ----- By
INSP. 11SIS 11300 Z6MTL-GP,
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9 0 9
Ciiy, of Edmond*
...RIGHT-OF-WAY CONSTRUCTION
-,PERMIT ber
Permit Num
Wue Date:
A. 'Address or Vicinity oP(A ustiuction. 21116 Pioneer Vy (9604814)
B. Type of Work (be specific): Install ServJLce
C. Contractor: Washington Natural -Gas
MailingAddress: 1199 15 qt SM Ezerett
State License #: 98203 -
D. Building Permit # (if applicable):
Contact: MarLame KJLugsbury
Phone: 3r.6-75nn X7596
Liability Insurance: Bond:$
Side Sewer Permit # (if applicable):
E. E3 Commercial [J Subdivision [_1 City Project [N Utility (PUD, GTE, WNG, CABLE, WATER)
Multi -Family C] Single Family E] Other
INSPECTOR: INSPECTOR:
F. Pavement or Concrete Cut: 0 Yes [JNo G. Size of Cut: X H. Chargq_$
APPLICANT TO READ ANJD,.SIGN
INDEMNITY. Applicant understands and by his signature to this application, agr sto Id the City ofEdmonds harmless from injuries, damages, or
claims of any kind or description whatsoever, foreseen or unforeseen, that may be made against the City of Edmonds, or any of its departments or
employees, including or not limited to the defense ofany legalproceedings including defense costs, and attorney fees by reason ofgranting thispermit.
f
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATER1ATS-FQR,,A PERIOD OF ONE Y&A`R FQI _10,WffG THE FINAL
INSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATiONiiiXg WILL BE HELD UNI 119AL-STREET PATCH
IS COMPLETED BY CITY FORCES, AT WHICH TIMEA DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT.
Construction drawing of proposed work required with permit application.
A 124 hour notice is required for inspection; Please call the Engineering Division, 771-0220.
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 copy of thepermit will be
available on site at all ti for inspeciion purposes.
Signature: Date: 12-8-95
M't r4 c t or o r 4 i e n t)
CALL DIAL -A -DIG PRIOR TO,.BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY: 1-,.Q t 4-&A RIGHT OF WAY DEPOSIT
TIME AUTHORIZED: . VOID AF`iER F-A YL DAYS
SPECIAL CONDITIONS:
DISRUPTION. FEE/FUND 111:
RESTORATION FEE:
PERMIT'FEE:
TOTAL FEE:
COMMENTS: RECEIPT
'B
.DATJE:. ISSUE<
NO WORK SHALL BEGIN PRIOR. TO PERMIT ISSUANCE
Eng. Div. 1994
FIELD INSPECTION NOTES
I Comments:
Diagram
(Fund 111 - Route copy to Street Dept.)
CONTRACTOR CALLED FOR INSPECTION El YES-" El NO
Partial Work Inspection by P.W.:
Work Disapproved By: Date:
FINAL APPROVAL BY: Date:
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V�Mwvbon-
Nd"Gasw`
Addendum to: City of FAmonds
Right of Way
Permit Application
Submitted by: Ma.riamwe Kingsbury
Migineeiring Aide
V"hington Natural Gas
1356-7500 X7596
0
jos 9COOH61H
2-111 Co 7P 10
vjY
Key:
-W- Water
Watermain depth :??I -G- Gas
-SS- Sever
-L2 gas main Water hydrant
0 Water valve
Washington Natural Gas Company
1122 75th Street SX. E%vrctt. Washington 98203. (206) 355-3331
HaturMGas��
Addendum to: City of Edmonds
Right of Way
Permit Application
Submitted by: Ma.riamne Kingsbury
Wneeiring Aide
Washington Natural Gas
1356-7500 X7596
$60
a
jc)e>. q(.,OOHe)IH
1(, 7P (0 oe�5
�-Kjy
Up
-V- Water
Watermain depth -G- Gas
-SS- Sever
gas main Water hydrant
0 Water valve
Ww-hington Natural Gas Company
1122 75th Street S.W.. E%vrett. Washington 98203. (206) 355-3331
MaturMGw
Watermain depth
_L_� gas main
Addendum to: City of Edmonds
Right of Way
Permit Application
Su . bmitted,by: ftrl�mne Kingsbury
Efigineeiring Aide
Vishington. Natural Gas
#3567500 X7596
a
Jos qc"OH61H
N 0 C—U-Fc��,
co P
-w- Water
-G- Gas
-SS- Sever,
Water hydrant
0
Water valve
Washiniton Natural Gas Company
1122 75th Street �X. Everett. Washington 98203. (206) 355-3331.
CITY OF EDMONDS
jg"'NEW
K __- MCI 05031
ADDITION�----
RETIREMENT
STRELAls qqjrRMATION SHEET
i
ASSET NO.
ADDITION TO ASSET NO-.,
I
DESCRIPTION
7
SERIAL NO.
LOCATION DEPT. NO.
"PURCHASE ORDER NO.
PURCHASE ORDER DATE
COST
B.A.R.S. ACCOUNT NO.
ESTIMATED LIFE
*PROJECT NUMBER."'j-1-15 -7
PROJECT COMPLETION DATE
COST
INITIATED BY DATE APPROVED BY
"SUBMIT ASSET INFORMATION SHEET WITH FINAL PAYMENT REQUEST
*SUBMIT ASSET INFORMATION SHEET UPON CLOSE',OF PROJECT
ACCOUNTING ONLY
$DEPRECIATE
MONTHLY DEPRECIATION AMOUNT
ANNUAL DEPRECIATION AMOUNT -
G.L. ENTRY
INITIAL
(vp)
REFERENCE
VERIFIED BY
PROCESSED
BATCH NO.
DATE
DEPARTMENT FILE
FROM: Engineering Division
Public Works Department
SUBJECT: ;�1111�2 ��/
Af ter rev i e-..i o f the subjec t Bu i I d i ng Permi t a ppl ica t ion , we have the fol I owi ng
commen ts :
I . Connection to City water system required.
2. Connection to City sanitary sewer system reqiiired. .
3. Right-of-way permit required for any work on City property.
4. Oriveway slope not to exceed 14*1
5. Backt-iater valve required if downstairs plumbina i-; below elevation ol'
U Lream manho e.
6. Water and sewer lines to be separated by 10 Foot minimum.
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HYDRANT REQUI RM
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USE IWPERMIT
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CITY OF EDMZMDS I NUMBER
f%^k1C%1rn" lnr% 1150115RAFr An1151 I A'rl^Li
JOB
NAME (OR NAME OF BUSINESS) ADDRESS
,6 vfeetg
z2f/LEGAL DESCRIPTION CHECKI SUBDIVISION NO.
4--a "o
MAILING ADDRESS 7-4-77
TITY TELEPHONE NUMBER PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP.
/N EXISTING P REQUIRED DEDICATION
NAME D Z4 tV
RIGHT OF WAY CONST RUCTION PERMIT REQUIRED
ADDRESS STREET USE PERMIT REQUIRED 0
SEE ENGINEERING MEMO DATED
1ITY __[rELEPHONE NUMBER
NAME
le-3 /,.)I m_)f METER SIZE
CITY TELEPHONE NUMBER
e-C-117 I REMARKS
STATE LICENSE NUMBER
S
j ALLOWED
Legal Description of Property - Include all easements
(show below or attach four cooles) I
r1l,
FIXTURE UNITS
EA ENV. REVIEW I ADB NO.
PROPOSED I COMPLETE I EXEMPT
VARIANCE OR CU
PLA&
56k--7�1�17 /,'P' -7- .271V tll,177,
4V--7
YARDS
FRONT SIDE REAR
EMARKS
NEW
ADDIALTER
REPAIR
DEMOLISH
REMODEL
RESIDENTIAL
COMMERCIAL
RETAINING WALL
EXCAVATE
OR FILL
PRE-MOVECNSPJ P.
COMPLIAN E INS
PLUMBING
MECHANICAL
SIGN
FENCE
X_ FT)
El
CHECKED BY
TYPE OF CONSTRUI
SPECIAL INSPECTOR
REQUIRED
0 YES , ONO
AREA
1 WOOD STOVE/
:1 INSERT
Ej APT.BLDG
RENEWAL
REMARKS
5 NUMBEROF
NUMBER OF STORIES
DWtLLINU
UN11b
NATURE OF WORK TO BE DONE (ATTACH PLOT PLAN)
REVIEW BY DATE
jTHEiGHT I LOT COVERAGE
'ION CODE HEIGHT
JOCCUPANCY OCCUPANT
GROUP )?=3 LOAD
—I!
Im !�� 60�_,
)A1 flo
VALUATION
PLAN CHECK FEE
BUILDING
PLUMBING
MECHANICAL
This Permit covers work to be done on private property Oi;LY.
GRADINGIFILL
Any construction on the public domain (curbs, sidewalks,
driveways, marquees, etc.) will require separate permission.
Permit Application: 180 Days
Permit Limit: 1 Year - Provided Work Is Started Within 180 Days
"Applicant, on behalf of his or her spouse, heirs, assigns and
successors In Interest, agrees to Indemnity, defend and hold
harmless the City of Edmonds, Washington, Its officials,
2
employees, and agents from any and 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
PLAN CHECK DEPOSIT
modify,.waive or reduce any requirement of any city ordinance
0
nor limit In any way the City's ability to enforce any ordinance
TOTAL AMOUNT D6E
provision."
1 hereby acknowledge that I have read this application; that the
Information given Is correct; and that I am the owner, or the duly
ATTENTION
APPLICATION APPROVAL
authorized agent of the owner. I agree to comply with city and
THIS PERMIT
state laws regulating construction; and In doing the work authoriz-
AUTHORIZES
This application Is not a permit until
ed thereby, no person will be employed In violation of the Labor
ONLY THE
signed by. the Building Official or his
Code of the State of Washington relating to Workmen's Compensa-
WORK NOTED
Deputy; and fees are paid, and receipt is
tion-Insurlinco,.
INSPECTION
acknowledged in space provided.
SIGNATURE (OWNER OR AGENT) DATE SIGNED
DEPARTMENT
CITY OF
OFFICIAL'S SIGNATURE DATE
EDMONDS ,
RELEASED BY: DATE
A I I til I IUIN
IT IS UNLAWFUL TO USE OR OCCUPY A BUILD-ING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR ORIGINAL — File YELLOW — Inspector
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED. UBC
CHAPTER 3. PINK — Owner GOLD — Assessor
102-78
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