21327 95TH PL W.PDF11111111 lill
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21327 95TH PL W
STREET FILE A/ e* A, 4
C I T Y 0 F E D M 0 N D S
- SEWER DEPARTMENT - 774
STOPPAGE OF SANITARY SEWER MAIN REPORT
DATE:
-Aw
TIME
CALL RECEIVED:
LOCATION OF STOPPAGE:
a):
r-->L- , -S va
TIME OF ARRIVAL ON THE JOB SITE: M *. 4ES� P, LA -
..Z' . -_�'
TIME NORMAL FLOW OF SANITARY SEWER REESTABLISHED: C5
CAUSE OF STOPPAGE:
ACTION REQUIRED TO CLEAR MAIN AND/OR LATERAL:
-t-t>T�Ewt-Z12- 2-c�DDe=sa-
-CITY CREIV ON STOPPAGE CALL OUT (Personnel Involved): J i i-A J t-,l
LOCATION OF RESIDENCE AFFECTED: 2. 1 7-> ^1 -1 - e-)-15133 N-">L- , 4eS.\A,/.
NAME, ADDRESS, AND PHONE NUMBER OF PROPERTY OWNER: TZ%e--O &2_0 WAL-4-ka-12
2-1 -32-1 - c: !� 15'Llc' T--> L_ - -S - \.kj - C-- N_3 0 S 11 W ki - )OZZ>
DESCRIBE DAMAGE TO PRIVATE PROPERTY: A(2_c�>uL_3E)
T- ec>v,/ �� !�=A
E n L_j L_�-r
ovvv L _4s, a es.. i D e vo c>q_ g- , ep AA_,c� e>
REMARKS: &TrArC_LU5-D
46 -.,,) /- 7(l,
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CLA:M DkM.AGFS
NOTICE RECEIVED
J U L 6 1976
Claim MUST be presented Ito the City Counci-I and fi-led with the City Clerk within 120 days
from the date of Accident or Accrual of Damages. Public Works Uepl-
TO THE CITY COUNCIL OF THE CITY OF EMONDS:
PLEASE TAIKE NOTICE, THAT L J<e
(if married, give husband's name)
-� I' C. :� I-. -, il A C - -I. �,s t — �--'
ViO NOIN RESIDES AT - --, ?) �) -1 1 Ui 0 a L-0
Ts-tate present actual address by street, number and city)
AND 17HO FOR SIX MONTHS PRIOR TO DATE OF ACCIDENT HAS RESIDED AT
--.I- t- CA��t—L' PL,, Uzist --Ei:
e residence by street, number and city
0IJ 3
CLAIMS DAMAGBS OF AND FROM THE CITY OF EDMONDS IN THE SUM OF S L� � 3. 0 2--
arising out of the following circumstances:
Describe Claim, giving
DATE and TIME injury or
damage occurred, PLACE
and full particulars.
Accurately locate an d
describe defects caus-
ing injury or damage
and all acts of negli-
gence claimed.
C',
Accurately describe J.,
injuries or damage �.1�0
0
State items of damage"
0
claimed. Itemize all
expenses and losses.
lla,C4-1
14,
A
0
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0 k- 0
FU
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7::�
IAIT 10
A C; e- 0
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0 V 6,;-.
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Or,\
(Claim must be sworn to by claimant)
(Signature of Claimant)
—mIBED AND SWORN TO
before me this _day of
V.,
�otary Publ c i n and I r'/the Str te of
ashington residing &Z
.7
v
Citywof-Edmonds
RIGHT-OF-WAY CONSTRUCTION
PERMIT Permit Number.
Z, 0 Issue Date:
A. Address or Vicinity of Construction: 21327 95 P1 W (9428187)
8 9 0 c) B. Type of Work (be specific): Zustall New -Service
C. Contractor: Washington Natural Gas Company Contact: Frank Swan
Mailing Address: 815 Mercer St., Seattles WAPhone: 224-2278
State License #: 98.L.L JL Liability Insurance: Bond: $
D. Building Permit # (if applicable): Side Sewer Perm#, # (if applicable):
E. [J Commercial Subdivision El City Project [A Utility (PUD, GTE, WNG, CABLE, WATER)
EJ Multi -Family 0 Single Family EJ Other
INSPECTOR: INSPECTOR: y') k
F. Pavement or Concrete Cut N Yes ONo G. Size of Cut: 1 L(:2
4) H. Chargq�,$
APPLICANT TO READ AND' N
V
t of Edm. rm ess om iurii-m a*ges, or
INDEMNITY. Applicant understands and by his signature to this application, agr es to old nds ha I
claims of any kind or description whatsoever, foreseen or unforeseen, that may e a � it City of Edmonds, oony of -its dejiaqment8 or
employees, includingornot limitedto thedefenseofany legal proceedings includi ee se sts, and attorney fees by reason ofW�hting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS
FEJ. LLPWIN. THE FINAL
Wff I
..,.RIOD OF ONE YEAR V
LL
INSPECTION AND ACCEPTANCE OF THE WORK. ESTIMATED RESTORATION FE S- LL EHELDUN WAY 'S i4MIET PATCH
IS COMPLETED BY CITY FORCES, AT WHICH TIME A DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT.
Construction drawing of proposed work required with permit application.
A 24 hour notice is required for inspection; Please call the Engineering Division, 771-0220.
ork- 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 abovestatements and understand thepermit requirements andthepink copyof thepermit willbe
available on site at all >ime&1,w inspection purposes.
Signature: Date: September 12, 1994
(Contractor or ,Ce`n-t7-
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY: RIGHT OF WAY DEPOSIT
TIME AUTHORIZED': VOID AFTER NQV 20 DAYS
SPECIAL CONDITIONS: L I A,
COMMENTS:
DISRUPTION FEE/FUND Ill:
RESTORATION FEE:
PERMIT FEE:
TOTAL FEE:
RECEIPT FEE:
,�i
DATE:
ISSUED BY:
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE Engrg. Nv. 1991
FIELD INSPECTION NOTES
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:
Yl-
vlow W vW ow IF
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city.
LANKF
SUbMI t-od.-byS PTCHELL, S.
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Key:
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-ss- sewer
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