22515 95TH PL W.PDFiiiiii ' 11 lill
9357
22515 95TH PL W
Roxl- (Luol
City of �dmonds, Permit No:
RIGHT-OF-WAY CONSTRUCTION PERMIT Issue Date:
A. Address or Vicinity of Construction.' (9 a 1,5 15 6, 19L, W
B. T e of Work I be specific) 00 c9 Cx i 'yi (P U ��g tJ 01- L
cr, r--,Z C9 �r 31- 's LJ_) f, 13 L 6,� 9 S 10 L' LJ
Bcw-e- E6e_ Hq -�0\0 fl 10 -70 ;) 1,57 9,5'
4t
d &, � '
C. Contractor: Contact: 3 L),Q. Ls,
Mailing Address: <40 0'e— & U /J Phone: (n)6(0 - (41 R -4, 0
State License #: LC H C 1:7 ) 0 1 Yn 4 Liabi . lity Insurance: Bond: $
'D. Building Permit # (if applicable): Side Sewer Permit # (if applicable):
E. F1 Commercial El Subdivision,,_"_�'E] CityProject E] EUC(PUi'),VERIZON,PSE,AT&T,OVWD)
(—,:,f.,e
F� Multi -Family Single Family Other
INSPECTOR:
F. PAVEMENT CUT: "'R "Y ES El NO
CONCRETECUT: [:]YES,,___[]NO
G. SIZE OF CUT :3 x 5—
AN)LICANTTO IZEAI) ANI) SIGN
INDEMN.,ITY.- Applicant understands by his/her signature to this application helshe holds the City of Edmonds 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 but not limited to the defense of any legal proceedings. including defense
costs andattorneyfees by reason ofgranting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOW1NG,TffE.,F7N4L
INSPECTION AND ACCEPTANCE OF. THE WORK ESTIMATED RESTORATION FEES W!LL BE HELD UNTIL THE FINAL STREETIPATCH IS-,,
COMPLETED BY CITY FORCES, AT WHICH TIME A DEBIT OR CREDIT 97LL BE PROCESSED FOR ISSUANCE TO THE APPLICANT
Traffic control and public safety shall be in accordance with City regulations as required by the City Engineer. Every
flagger must be trained as required by (WAC) 296-155-305 and must have 'certification verifying completion of the
required training in their possession.
Restoration is to be in accordance with City codes. All street -cut trench work shall be patched with asphalt or City -
approved material prior to the end of the workday — NO EXCEPTIONS.
Three sets of construction drawings of proposed work are required with the permit application.
CALL DIAL -A -DIG (1-800-424-5555) PRIOR TO BEGINNING WORK
IHAVEREAD THE ABOVE STATEMENTS AND UNDERSTAND THE PERMIT REQUIREMENTS AND ACKNOWLEDGE
THA TI MUSTMAKE THE PINK COPY OF THE PERMITA VAILABLE ONSITt AT ALL TL4ES FOR INSPECTIONS
Signature: Date:'
(Contractor or Agent)
FOR CITY USE ONLY
Approved by:. .11 J Right-of-way Fee:,o /to 0
Time Authorize&. -Void After
'Special Conditions-�c _t*;L-oF-\.41Ay 7294&&-Restoration Fee:
K"Al tw Total Fee:. 3 7.5-- CV
'Sor� PA P_ Ar i Qti -;:Q-OA4 A i i-, rn-v OF F�JDA40,y ixz Receipt No:
6Lr_L1,jVa . 041, 4:�oiz Lor-4rr—, r.,,,c o14 1,Ing-177w< Issued
A - - I- r .
rA I-- P--,ftA- ri _1= =6 f4.L L_ T- Lf* !&w rw C_
IC7,
E140 P2L_rSa-.
r49- SrAsl: A�N L
-PERMITT,;E-E�7W-ORK9,AN-EN.GINEERING�FINAL-
NUOMPLETION�OF
INSPECTION IS REQUIRED PER CHAPYE", .00 OF THE EDMONDS
COMMUNITY DEVELOPMENT CQDE�A.one 425-771-0220, Ext 1326)].
L
FINAL APPROVAL OF PERMITTED WORK. Z' DATE:J 1'0'5[6"
Ynspector's Signature
For inspection requirements see Engineering Inspection Information handout.
Vilchuck. Contractors, Inc
Job # 107021585
October 25, 2004
Sheet 1/1 Rob Inglis CTHY
OM
GWOU
WORK AREA 3'x 5!
IN GRASS SHOULDER
1=
CHANNELIZATION DEVICE SPACING
MPH
TAPER
TANGENT
50/70
40
80
35/45
30
60
25/30.
20
F�
-j
CL
�2
10,
PAV
LU
t
22515
0
ROAD
WORK
AHEAD
228th ST SW
APPROVED AS NOTED
BY ENGINEERING
Notes:
1. All signs and spacing to conform
to the City of Edmonds Traffic Control
specs.
2. ChannelizIng devices are 28"
traffic cones.
3. All signs are 48" x 48" B/O unless
otherwise specified.
4. Alert affected residents.
5. Work to take place between 9 a.m.
And 4 p.m.
LEGEND
28" TRAFFIC CONE
WORK AREA
TRAFFIC FLOW
FLAGGER
SIGNAL LIGHT
WORK VEHICLE
SIGN LOCATION
61
SIET
0
PLOT
.v
30, -ro csws. L-Ime. STREET FILE
f,y I sm N 6
z-z7s�sq pr
APPROVED BY PLANNING
72 A o-,
m
MUM
Lum
17
Commm.
=.e�wrtflfs come,
rlw9- -M VcM
* ser fty-
?Mflom-To W- so- CQ
f-AsTwG C-004Rgm
ofkwl'iA*
S uOrs -ro gem Pa 0
ADD GUTTERS /DOWNSPOUTS
AND OPLASHBLOCKS
APP19(""VED AS NOTED
BY ENGINEERING
Date;
OWNER/CONTPAC-TOR IS RESPONSIBLE
FOR EROSION CONTROL AND DAMAGE
STANDARD GAS CONSTRUCTION NOTES:
1.
FIELD LOCATE ALL UNDERGROUND UTILITIES. EXCAVATOR TO CALL 'ONE -CALL" TWO WORKING DAYS PRIOR TO
TO CONSTRUCTION, IN WESTERN WASHINGTON CALL: 1-800-424-5555. IN KITTITAS COUNTY CALL: 1-800-553-4344
2.
NOTIFY APPROPRIATE PERMITTING AGENCY PRIOR TO JOB START (SEE PERMIT REQUIRMENTS).
3.
ALL CONSTRUCTION IS TO CONFORM TO PSE GAS OPERATING STANDARDS AND GAS FIELD PROCEDURES.
4.
EROSION AND SEDIMENT CONTROL SHALL BE PER PSE STANDARD PRACTICE 0150.3200 TECHNIQUES FOR TEMPORARY
EROSION AND SEDIMENT CONTROL AND ANY ADDITIONAL LOCAL JURISDICTION REQUIREMENTS.
224TH
ST. SW
5.
NOTIFY PROPERTY OWNERS ADJACENT TO PROPOSED CONSTRUCTION ACTIVITIES A MINIMUM OF TWO WORKING DAYS
PRIOR TO BEGINNING CONSTRUCTION. USE iSi TO DISTRIBUTE FLYERS IF JOB IS LARGE, OTHERWISE HAND
DELIVER FLYERS BE SURE TO INCLUDE THE LIST OF FREQUENTLY ASKED QUESTIONS AND INFORMATION ABOUT
THE OPPORTUNITY TO PURCHASE AN EXCESS FLOW VALVE WHEN THEIR SERVICE IS INSTALLED OR REPLACED
PER GAS OPERATING STANDARD 2550.1600. ALLOW ADEQUATE TIME FOR CUSTOMER DECISION AND RESPONSE.
6.
ANY CHANGE IN ROUTE, PIPE SIZE/TYPE, TIE -IN METHOD OR ADDITIONAL MAIN FOOTAGE MUST BE APPROVED BY
THE APPROPRIATE PSE ENGINEER OR PSE REPRESENTATIVE.
7.
COMPLETE "PIPE CONDITION REPORT" ON ALL METALIC'PSE FACILITIES. CHECK BOX ON REPORT FOR WIRE
13OX (TEST LEAD) INSTALLATION.
8.
PIPELINE MARKERS AND WARNING SIGNS SHALL BE INSTALLED AND RECORDED BY THE CONTRACTOR PER PSE GAS
OPERATING STANDARD 2525.2500.
20' ASPHALT
9.
INSTALL MAIN VALVES OUT OF TRAFFIC WHERE POSSIBLE. VALVE MARKERS SHALL BE INSTALLED AND RECORDED BY
THE CONTRACTOR PER PSE GAS OPERATING STANDARD 2525.2600 FOR ALL HP VALVES IF THE LOCATION IS
20' CRASS
NOT READILY ACCESSIBLE, AND FOR ALL VALVES WHERE PERSISTANT SNOWFALL MAY OBSCURE THE VALVE BOX.
BOTH SIDE
10.
TO PREVENT ACCIDENTAL OVERPRESSURE OF ADJOINING SYSTEMS, NO TWO MAINS SHALL BE CONNECTED EXCEPT AS
SHOWN ON THIS DESIGN UNLESS APPROVED BY APPROPRIATE PSE ENGINEER OR'PSE REPRESENTATIVE.
11.
SYSTEM MAOP DENOTED BY: I SYSTEM MAOP = -AL PSIG
EOM
C4-
2" PE CAP
12.
GAUGE AND MONITOR USE OF ALL STOPPERS TO ENSURE ADEQUATE FEED.
688'N CL & 13'W CL
Rf�
13.
RESTORE ALL DRIVEWAYS SUBJECT TO OPEN CUT TO ORIGINAL OR BETTER CONDITION.
--- 10 CL (---')W CL
Z\D
14.
PURGE POINTS AND PRESSURE TAPS TO BE INSTALLED PER PSE GAS OPERATING STANDARDS 2525,3300, AND 2525.1200.
PL
15.
MAINS AND SERVICES SHALL BE TESTED AND PURGED PER PSE GAS OPERATING STANDARDS 2525.3300 AND 2525.3400.
PROPOSED 50'
CY,
16.
IF METALLIC PIPE IS INVOLVED, COORDINATE INSTALLATION WITH �CP TECH.
2" PE IP MAIN-----\,)
---------
PHONE ---------
13'W CL W CL
17.
NOTE ALL ACTUAL FOOTAGE, LOCATION AND MATERIAL CHANGES ON THE AS -BUILT IN.RED. DENOTES
0. 4 k4
FOOTAGE BETWEEN FITTINGS.
TIE- IN FUSE
638'N CL & 13'W CL
(---')N CL (---')W CL
1`3 c) 4-
C-)
,_9
(I
L
60'
R/W Rj/w
1-20' GRASS 10, 10,
ASP HALT_�_ASP HALT
PROP. 2" GAS
13'W CL
00
M
r"A
uej �B�
228TH ST SW � W
95TH PL W
TYP. ROAD SECTION
SCALE: NONE
�—f 5' WA TER
19,
OVERHEAD POWER
M
PLOT PLAN
SCALE.- I = 50'
R/W
20' GRASS
EX. WATER
15'E CL
ul;
F17ER (CHECK BOX IF COMPLETE)
Work area left in Clean & Safe ondition
Complete all Pipe Tables and Gas Pressu-re Stamp
Field changes Red —Lined on as —built
Material verified and Changes noted on I)aperwork
All Valve & Tie — in Locations noted on cs—built
Note beginning of Main, EOM & Line of Main locations
Show Rope Locations & Cul—de—sac Radius
Foreman's Signature
Company
Date
GAS MAIN INSTALLATIONIRETIREMENT
Type[Work
Pipe Size
Type
Estimated
Length
Actual
Length
Manufacturer
INSTALL
2"
PE
50,
GAS MAIN'PRESSURE & TESTING
TYPE TEST
PRESSURE-
TESTED BY
DATE ON
TIME ON
DATE OFF
TIME OFF
TYPE TEST
PRESSURE
TESTED BY
DATE ON
TIME ON
,DATE OFF
TIME OFF
I Design Press 60
1 SYS MAOP 45
PROJECT PHASE
NOTIF#
ORDER#
SAP Supedor
Service/Meter
Service/Meter
Service/Meter
Service/Meter
Ind. Service
Ind. MSA
Dis. Reg. / FT
HPSvdMSA
Relocate
Retirement
X244239639
107021585
X820514215
106139076
Contractor CONSTRUCTION COST CODES:
041-103-1 1 1 1 1
Project Manager Contact Information:
KIM GRAY
CELL: 425-290-2678
EMAIL: kim.GRAY@pse.com
Vicinity Map
WORK SITE
T 2'
&q
FO '4) 2� 4- � H- a -
I I IT
ED
::i
mul
01
Owner/ Developer Contact Info
JAMES KEITH
22515 95TH PIL W
EDMONDS, WA 98020
ATTN: SAME 425-778-0039 office
CALL (800) 424-5555
2 BUSINESS DAYS BEFORE YOU DIG
THIS SKETCH NOT TO BE RELIED UPON FOR EMT LOCATION OF FACIUTIES
REAL ESTATE/EASEMENT PERMIT
NIA CITY OF EDMONDS
REV#
DATE
BY
DESCRIPTION
FUNCTION
CONTACT
PHONE
DATE
3
PROJECT MGR
KIM GRAY
206-418-4233
10125/04
2
ENGR-GAS
DRAWN BY
VII DANG
206-418-4257
10125/04
CHECKED BY
KIM GRAY
206-418-4233
1110101�4
COUNTY
EMER SECT
GAS WK CTR
APPROVED BY
KIM GRAY
206-418-4233
110125104
0
SNOHOMISH
5
MCNSEG
CP APPROVAL
11
1/4 SEC
OP MAP
PLAT MAP
1:1
SE 25-27-03
1 164.062
1 165.067
IMAPPING
JOINT FACILITIES ARRANGEMENTS
1:1
UTILITIES
1:1
El
CONTACT
El
PHONE#
PUGET
SOUND JAMES KEITH
ENERGY 2" PE IP MAIN EXTENSION
22515 95TH PL W EDMONDS, WA 98020
DESIGNED BY PILCHUICK CONTRACTORS INC.
SAP Superior Order:
107021585
Drawina Number:
SCALE: PAGE
III = 50' 1 1 /1
CA FILE NO.
Critical Areas Checklist
----------------------------------------------------------- 7--
Site Information (soil s/topography/hydrology/vegetation)
1. Site Address/Location: '2-aS i L,/, 9� A) 1�� tVPk_
2. Property Tax Account Number: .4&t 44 Lj ",7> G 0 0 7
3. Approximate S ite S ize (acres or square feet): 0
4. Is this site currently developed? yes; _ no.
If yes; how is site developed? \Z C
5. Describe the general site topography. Check all that apply.
Flat: less than 5-feet elevation change over entire site.
Rolling: slopes on site generally less than 15% (a vertical rise of -1 0-feet over a
horizontal distance of 66-feet).
Hilly: slopes present on site of more than 15% and less than 30% ( a vertical rise of
I 0-feet over a horizontal distance of 3 3 to 66-feet).
S teep: grades of greater than 3 0% present on site (a vertical rise of I 04�et over a
horizontal distance of less than 33-feet).
Other (please describe):
6. Site contains areas of year-round standing water: k Approx. Depth:
7. Site contains areas of seasonal standing water: Approx. Depth:
What �eason(s) of the year?
8. Site is in the floodway floodplain of a water course.
9. Site contains #,creek or an area where water flows Icloss the grounds surface? Flow are year -
Al 2*T--
round? Flows are seasonal? (What time of year?
10. Site is primarily: forested meadow shrubs mixed
urban landscaped (lawn,shrubs etc)
11. Obvious wetland is present on site: 6k_9
6. Site designated on the Environmentally Sensitive Areas Map?
Am_chkAoc; Rev 10/03/97
ED
City of Edmonds
Development Services Department
Planning Division
Phone: 425.771.0220
Fax: 425.771.0221
Critical Areas File #:
Critical Areas Checklist Fee: $4&00
Date Received by Dev. Serv. Dept:-- J)JA f&W
City Receipt No:
Date Mailed to Applica�t:
CRITICAL AREAS CHECKLIST
The Critical Areas Checklist contained on this form is
to be filled out by any person preparing a
Development Perm�it Application for the City of
Edmonds Prior to his/her submittal of a development
permit 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).
An applicant, or his/her representative, must fill out
the checklist, sign and date it, and submit it to the
City. The City will review the 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 finding and
locating the specific piece of property described on
this form. In addition, the applicant shall include
other pertinent information (e.g., site plan, topoiraphy
map, etc..) or studies in conjunction with t his Checklist
to assist staff in completing their preliminary
assessment of the site.
I have completed the attached Critical Areas Checklist and attest that the answers provided are factual, to the
best of my knowledge (fill out the appropriate column below).
PLEASE PRINT CLEARLY
Owner/Applicant:
Name
'22
Street Address
A/kC)(\-) L&I
city State Zip
:2 2L do 2
Telephone
_7 1'1-63
Date
d:receptiorylanatCACLHandout.doc
Applicant Representative:
Name
Street Address
City State zip
Telephone
Signature
Date
Revised 411 D/2000
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ez f
A,TE RECEIVED
V� FPERMIT EXPI RES4�WZ
CITY OF EDMONDS
USE PERMIT
ZONE ;27
NUMBER=&
CONSTRUCTION PERMIT APPLICATION
JOB SUITEIAPT#
ADDRESS
&
0 W�IER OF BUSINES
PLAT NAME/tUBDIVISION NO.
LOT NO
LID NO.
fMEINAME
MAILING ADDRESS f
9<9
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Pamit Required 0
0
Street Use Permit Req'd C3
EXISTING PROPOSED
Inspection Required 0
Sidewalk Required 0
CITY — ZIP
TELEPHONE
&Z"Mb.C_2 991�w
771-C-g-V -
REQUIRED DEDICATION— FT
U=rground 0
Wiring required
NAME
METER SIZE
LINE SIZE I
NO. OF FIXTURES
PRV REQUIRED
YES E3 NO 13
3
W
r
ADDRESS
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
CITY ZIP
TELEPHONE
NAME
ENGINEERING REVIEWED/DATE
ADDRESS
CC
FIRE REVIEWED BY DATE
M
ease
0
CITY ZIP
TELEPHONE
VARIANCE OR CU
SHORELINE OR ADB#
INSPECTION
REO'D
BOND
POSTED
STATE LICENSE NUMBER EXPIRATION DATE
CHECKED BY .
YES NO
SEPA REVIEW
SIGN AREA
HEIGHT
-j
PROPERTY TAX ACCOUNT PARCEL -NO.
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED ,.PROPOSED
14
FXP I
I
RESIDENTIAL
0 14EW PLUMBING f MECH
0 COMMERCIAL COMPLIANCE OR
rl ADDITION X9CHANGE OF USE
0 REMODEL. C] APARTMENT SIGN -
LOT COVERAGE
ALLOWED PROPOSED
'REQUIRED SETBACKS (FT.)
FRONT SIDE REAR
PROPOSED SETBACKS (FT.)
FRONT URSIDE REAR
z
z
PARKING
REO'D I PROVIDED
LOT AREA
PLANNING REVIEWED BY DATE
.A FENCE
C3 GR DING
REPAIR CYDS FT)
e.
EMARKS
C] DEMOLISH C] TANK OTHER
z
I=
GARAGE RETAINING WALL 0 RENEWAL
CARPORT ROCKERY
(TYPE OF USE, BUSIN SI�OR ACTIVITY) EXPLAIN:
I
CHECKED BY
TYEE OF CONSTRUCTION ICODF.
jrn.1:-__4jj
OCCUPANT
GROUP
LL
W
0
100
NUMBER
OF
STORIES
NUMBER OF
DWELLING
UNITS
CRITICAL
AREAS
NUMBER
SPECIAL INSPEbfOR
REQUIRED [:] YES
AR�A OCCUPANT
LOAD
DESCRIBE WORK TO BE DONE
J
RE MARKS
PROGRESS INSPECTIONS PER UBC 1081FINAL INSPECTION REO'D
A
01
.1
VALUATION I FEE
PLAN CHECK FEE
HEAT SOURCE GLAZING % LOT SLOPE %
I E(:z I
BUILDING
-
PLAN CHECK NO: VESTED DATE
PLUMBING
MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO.
!Z BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
GRADING/FILL
2 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
M
SEPARATE PERMISSION.
ITATTMRCH
PERMIT APP
uj LICATION: 180 DAYS
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SRPq$ -E, HEIRS, ASSIGNS AND SUCCESORS
ENG. INSPECTION FEE
IN INTEREST, AGREES TO INDEMNIFY� DEFEND AND HOLD HARMLESS THE CITY OF
LANDSCAPIC40
X EDMONDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
INSPECTIO� FEE
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
RECEIPT
FROWtht IA$LIANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
DEE91ED Td&bf�� WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
X.
TOTAL AMOUNT DUE
R
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-
CALL
This application is not a permit until signed by the
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 r c P, is acknowledged in space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
/ALS
SIG TU (OWNER R AGENT) DATE SIGNED
QFF)L4 SIGNATURE DATE
(425)
L
771-0220
Y DATE
A ENTION
EXTA33
I IS UNLAWFUL TO USE OR OCCUPY A BUILDING 08 STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL -FILE YELLOW- INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
PINK - OWNER GOLD - ASSESSOR
5/98
ATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
MAILING ADDRESS
CITY ZIP TELEPHONE
NAME
ADDRESS
CITY ZIP ITELEPHONE
NAME
ADDRESS
CITY ZIP I TELEPHONE
PERMIT EXPI RES
USE PERMIT
ZONE
2009691
NUMBER
JOB SUITE/APT#
ADDRESS
PLAT NAME/tUBDIVISION NO.
LOT NO.
I
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved 0
RW Penrift Required 0
EXISTING PROPOSED
Street Use Pemill Req'd 0
Inspection Required 0
Sidewalk Required 0
REQUIRED DEDICATION— FT
Underground
wiring required 0
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
I
YES 0 NO 0
— tu
REMARKS z
z
OWNER/CONTRAi rOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE 0
z
uj
STATE LICENSE NUMBER I EXPIRATIONDATE I CHECKEDBY .
PROPERTY TAX ACCOUNT PARCEL NO.
C] NEW
RESIDENTIAL
C] PLUMBING / MECH
AUDITION
COMMERCIAL
o COMPLIANCE OR
CHANGE OF USE
REMODEL
APARTMENT
C] SIGN
0 REPAIR
GRADING
FENCE
0
C YDS"
X FT)
r-1 DEMOLISH
TANK
o OTHER.
o GARAGE
CARPORT
0 RETAINING WALL
nCCKr
=RY
C] RENEWAL
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
A5�6 zb 6--Al 77
NUMBER
NUMBER OF
CRITICAL.1 "/1)
OF
DWELLI
A
STORIES
UNITS
N
DESCRIBE WORK TO BE DONE
1tQSTAL-L_(D O%Jf- 100 fiAL
P" Ali OL
ENGINEERING REVIEWED/DATE
FIRE REVIEWED BY DATE
W
cc
VARIANCE A CU
SHORELINE OR ADB#
INSPECTION
REO'D
PSOND
OSTED
0 YES (:) NO
SEPA REVIEW
SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
EXP I
I
I
LOT COVERAGE
REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT UR SIDE REAR
Le
z
z
PARKING
LOT AREA
PLANNING REVIEWED BY DATE
REO'D I PROVIDED
I
CHECKEDBY I TYPE OF CONSTRUCTION CODE OCCUPANT
GROUP,/2-
7�� 1677:
SPECIAL INSPECTOR JAREA OCCUPANT 4'
REQUIRED 0 YES LOAD
a
REMARKS
PROGRESS INSPECTIONS PER UBC 1081FINAL INSPECTION REO'D 5
PLAN CHECK FEE
HEAT SOURCE GLAZING % LOT SLOPE % BUILDING
L
PLAN CHECK NO: VESTED DATE PLUMBING
34?/ MECHANICAL
VALUATI ON FEE
THIS OERMIT AUTHORIZES ONLY THE"WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
GRADING/FILL
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
CHARGE
PERMIT APPLICATION: ISO DAYS
PERMIT LIMIT! I YEAR - PROVIDED WORN STARTED WITHIN 180 DAYS
ENG. IEW FEES
66
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
ENG. INSPECTION FEE
IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
4AW1iQA9W1s —
X EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
< ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
C T
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
/w
DEEMEDTOMO DIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
L
IRECEPT
0 NOR LIMIT IN ANYWAYTHE CITY'SABILITYTO ENFORCE ANYORDINANCE PROVISION.-
X1
TOTAL AMOUNT DUE
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-
CALL
This application is not a permit until signed by the
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'S COMPENSATION INSURANCE AND RCW 18.27.
OF
IALS SIGNATIUR,15---, DATE
Sl A OWNE ORAGENT)
T!��o
DATE SIGNED
(425)
t
771-0220
-R
_
-
BY DATE
A-rfENTION
EXTJ 3:33
,�qASED
4,
OR OCCUPY A BUILDING OR STRUCTURE UNTIL
12
IT IS UNLAWFUL TO USE
n-4 ?.
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL -FILE - YELLOW-IASPE6TOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
PINK - OWNER - GOLD - ASSESSOR
5/98