22912 102ND PL W.PDF1111111111
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22912 102ND PL W
Critical Areas -Checklist
Site Informat i �6n (Soils/topo'
graphy/hydrology/yegetation)
L Sit on:
2.
unt inber too 9"
Nu :A /0 -7 061 0.2,
3- "o�itaa�e:�ye Size (acres or Square feet):
4. Is this ote a developiqd?. __!::::'_`yes; no.
Wit jgy
is site devel
W YtAe1s1;'% lo w oped?—,&//-< P /9"4,) 2W
5. Describe the general site topography. Ch all d= a
eck pply
evatiod clia�
Flat: less than 5 over entire site.
Rolling: slopes on site generally less than 15% (a vertical riseof 10-feet -over a
horizontal distance of 6&feet).
Hilly: slopes present on site of more than 15% and less than 30% a vertical rise,
of 10-feet over a horizontal distance of 33 to 66-feet).
Steep: grades of greater than 30% present on site (a vertical rise of I 0-feet over a
horizontal distance of less dian 33-feet).
Other (please describe):
6. Site.contains areas of year-round standing water /1/0
Approx. Depth:
7. Site contains areas of seasonal standing�'vater_ _ A?�o Approx. Depth:
What season(s) of the year?
8. Site is in the floodway A,/Q floodpWin 61,6 of a water course.
9. Site contains a creek or an am where vrAer flows across the grounds surface? Flows are year-
round? Flows are seasonal? (What time of year?
10. Site is primafily: forested meadow shrubs mixed
urban landscaped (lawn,shrubs etc)
11. Obvious wetland is present on site:
-For City Staff Use Only
I. Site is Zoned? 9
2. kS mapped soil type(s)? up.
--- 7-
3. Wetland inventory or C.A. map indicates wetland present on site? A10
4.-... :',-Critical Areas inventory or C.A. map indicates Critical Area on site? V05 66W
5. within' designated earth subsidence landslide hazard area? A-V
6. * ifte designated on the Environmentally Sensitive Areas Map?
BE
METERMINATION
`--`§TUDY REQUIRED
CONDITIONAL WAIVER
14 WAIVER
Reviewed by:
Planner 01' Date
P-W 0 1104V4
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Critical Area'
,s..,Qhi,e.c st...-
U e Criticalmeas c h
On ---.=d idbihit it to &e Cily. ne City wi
this form is to be filled out by
3" pawn, review st,. make a te
flyfij
rep' thedleCkli. pr si
P anngaDevelopme�tpennit ecur-Sory-
Application for the City of Ed �ik�nd makieadete�minati6nof the
monds prior subsequent
to his/her submittal of a demlopment- St"Ps necessary to complete a -
permit to the City. devetVfimt. permit .4pl icatioin'.
With a signedcopy of this jo— '""the
Ile PurPoseof the Checklist is to enable rm
aPPUcant should also submi�t a vicinity map
City staff to determine whetheany
Potential Critical Areas are or may be �r PI& plan for individual lots ofithe parcel
with cnoqgh detail that City staff can find.
present on the subject property. -ne
information needed to complete the and identify thesubject parcel(s)_ In
addition, the aPplicant shall incii�&
Checklist should be easily available from other pagnent inform. ation
observations of the site or data available at
M4 tOP09MPhY amp, etc.) or Studies in'
PL
City Hall (Critical Areas inventories, maps, conjunction with this Checklist to assist
or sod' surveys).
staff in COMPlefing their pre ' liminary.
assessment or the site.
An applicant, or his/her representative,
must fill out the checklist, sign and date it,
I have completed the attached' Critical Area Checklist and attest that the answers provided are
factual, to the best of my knowledge (fill out the appropriate column below).
Owner/ Applicant: Appricant Representative:
Nagme Nam
93x-7 4/
btreet Address
Street Address
aye
City, State, zip. Phon� City, State, ZIP Phone
6 919 a
SAignat
7,63R, Signature Date
117 c.-.- ' Is 9 Q
City of Edmonds
RIGHT-OF-WAY CONSTRUCTION
PERMIT -permit Number- *W 9-9-0 Z4-
Lqsue Date: Aq
A. Address or Vicinity of Construction: - *Z Z"/ I Z - 10 Z#JQ Sr 5 - (/0
B. Type of Work (be specific): P1g-rA0P/2o%/" PLA-" f) 8- & 4-
. 9--9JI-bb
C. Contractor: Contact: SuA)qQAS-T'
Mailing Address: 'P.O. 6D C YA)'AIAIQQD Phone:
State License #: V1k1JP1 i3l:M Liability Insurance: Bond: $
D. Building Permit # (if applicable):
Side Sewer Permit.#, (if applicable):
E. F1 Commercial RrSubdivision E] City Project E]'Utility" (PUDi GTE, WNG, CABLE, WATER)
E] Multi -Family El Single Family n Other
INSPECTOR: W A f Tt'v Tr INSPECTOR:
F. Pavement or Concrete Cut: . OYes ONo G. Size of Cut: x— H. Chargi�,$:
APPLICANT TO READ AND SIGN
INDEMNITY: Applicant understands and by his signature to this application to hold the City of Edmonds harmlessfrom injuries, damages, or claims ofan�
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 of any legal proceedings including defense costs and attorneyfees by reason of granting thispqrmit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL INSPEC-
TION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREETPATCHIS COMPLETED
BY CITY FORCES, AT WHICH TIME A DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT.
Two sets of construction drawings of proposed work required with permit application.
A 24 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 trench work shal I be patched with asphalt or City approved material prior to the end of the working day;
NO EXCEPTIONS.
I have read the above statements and d rstand the permit requirements and the pink copy of the permit will be
available on site alltimesfforinspe ionpurp es.
A/� Date:
Signature. x4f I 'oAff �� -
'(Contractor or-Ag,e
,F
CALL DIAL- fG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY: & e, ki
TIME AUTHORIZED: VOID AFTER_/ DAYS
SPECIAL CONDITIONS: PE-4 P(,PrAJ A:S
WDO 1:0 1?— a -0 C' ITY 'S eg V I r- ts
RIGHT OF WAY FEE:
DISRUPTION FEE/FLYND I 11:
RESTORATION FEE: d
T OTAL FEE: -
RECEIPT NO.: //1 /9-3 4;7�
ISSUED BY:
NO WORK qJ4A1J, RRGIN PRInR TO PFRMIT ISSUANCE P— ni� 109"
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:
�0000
/n - Soo
C..
city 'of EUmonds
RIGHT-OF-WAY CONSTRUCTION
PERMIT Permit Number. 99 ap
.A. Address or Vicinity of Construction:
B. Type of Work (be specific):
C. Contractor:n))�A - , 14 J#Z%A7��
Mailing Address:
State License #:
D. Building Permit # (if applicable):
Issue Date:
Contact:
Phone: 422� -1-74--7721qq
Liability Insurance: Bond:
Side Sewer Permit # (if applicable):
E. E] Commercial E] Subdivision El City Project 0-Ut.1lity (PUD, GTE, WNG; CABLEgj�V_TE
E] Multi -Family E] Single Family Other U.A. 7
INSPECTOR: INSPECTOR: R.Li
F. Pavement,or Concrete Cut: 0 Yes' WNO G. Size of Cut: x H. &argic$`
APPLICANT TO READ AND SIGN
INDEMNITY: Applicant understands and by his signature to this application to * hold the City of Edmonds harmlessftom 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 of any legal proceedings including defense costs and attorneyfees by reason of granting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL INSPEC-
TION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES WILL BE HEI!D UNTIL THE FINAL STREETPATCHIS COMPLETED
BY CITY FORCES, AT WHICH, TIME A DEBIT OR CREDIT W11 L BE PROCESSED FOR ISSUANCE TO THE APPLICANT
Two sets of constr*uction drawings of proposed work required with permit app'*lication,
A 24 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 trench work shall be patched with asphalt or City approved material prior to the end ofthejwo�king day;
NO EXCEPTIONS.
I have read the abovAtatements and understand the permit requirements and� the pink copy of e permit will be
th'
available on site at all times fominSDection-VUrnows.
Signature: Date: 4f�Aw I
(gontr &tor or Agi
_Ulu TO BEGIN N-ING WORK
FOR CITY USE ONLY
APPROVED BY:
TIME AUTHORIZED: VOTI) AFTER lo DAYS
SPECIAL CONDITIONS: � A
RIGHT OF WAY FEE: 7-D, 0 0
DISRUPTION FEEIFUND i I I:'
RESTORATION FEE:
T OTAL FEE:
RECEIPT
11 ISSUED BY",:
NO WORK SHALL BEGIN PRIO R TO PERMIT ISSUANCE Eng. Div 1997
FIELD INSPECTION NOTES '(Fund 111 —Route copy to Street Dept.)
Comments:
CONTRACTOR CALLED FOR INSPECTION 1-1 YES NO
Partial Work Inspection by P.W.:
Work Disapproved By: Date:
FINAL APPROVAL BY: Date:
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