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23040 75TH AVE W
The City of Edmonds Water Service Drawing EASEMENT . NO . ................................. .....
NEW CONSTRUCTION REPAIRS LID NO . .................. . ASMT. NO . ..................
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OWNER............................................................................................ ... CONTRACTOR .................................................................................... PERMIT NO. loc>.. .
LEGAL DESCRIPTION: LOT. NO . ................................ -.. 131;,�.,K NO. ..— ...............................
JOB ADDRESS A,* .............................
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... ............................. ...........................
............................................... .............................................
NAMEOF ADDITION ...................... .................................. ........................................... ..............
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Approved:
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DAT E ... By .
w4w-0oui-11175 (REV.11 1178)
0
'A* APPLICATION
Me City of Ecktiands for EASEMENT NO . ................. ------------------------
SIDE SEWER PERMIT
NEW CONSTRUCTION REPAIRS LID NO. YD& ..... ASMX. NO.
OWNER --- ............. ......... ............ CONTRACTOR t-J.t-.4.t.-TF-Cl� ...... P-LUM-E:A-"(a ........... PERMIT NO.
.... .. .. ......... ..... ---- --------------- ------ ------------
JOB ADDRESS .... — ----- LEGAL DESCRIPTION: LOT NO!�� --- �-AQ ------ BLOCK NO - ------------------------------------
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NAMEOF ADDITION ---------------------------------------------------------- ............................................................
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tT-Y,'�;L-EG-A�L","DES,CRIP,-TION ...................................................... i: ........ .............. ................. ......... ...................................
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�No�:�`,*T-] iowners)j�du ji�heYWrol�e�,iy.`may - of;tain-iL,.,riermit'+�to:-cc;nat rucit .'isewer insIde`,'p�ojje k,'min ,Iic�n S.�+. e
.1 .., , . . I _. . I - � - I . !Sewer�C_6treq7qrj rnus�,, e�ernpiM,
isidellsewerlinti t�area,� - Do�'n ot"66wet', an�q>ort ion, ovsctIter.'�I;cfor��-itv h sl,b�eit�pris5ected� ji
-�2�,Akillw.ork�,pbrfprmedlitni,city,.�rightr t-of7wwPermiti:o� a*j n-a
'Of-NaY$)requir6st-,a�',[�ln�"i�n�;oi-4�Righ* t "bl'e"f'if-+orii�'�t�*6�iCit�!,Enkiiie6r,��k'o'ilige'.!,.,t'"",',��l.�;ia
-No,,-.13�—'ObtaInMuI1j1inf
NOTE:,No , 4 '—Top, df.�sid6,sewer.,,must.,have'-'a't fe - ast' 36; inc"hi;�,.c6v�rag , e -at proRer�y 11�� j -rnin'l�'i6m�'gradc�jof,2 -,;NoT,-P si!i I';
;No,, b r
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1A ttib�epernnitted.,
NOTE �6�,5��Trenchesi+inl,stir�e��,mu��,�be�,N�a�er,�ettl'��l�j��d,sur�a'e,; f -str�etT rehtored', to original�coriditicl&.. Con ractors,,shal
w�be, r�spbiisi6lef,for,','fi�llar6f�due,.to tlmpiiop�er
-may,,developrwithin,�on��'yea�,dfl:com�l.Ctib.n'.,
OTE)1.14��-`&L�It, 1i;,Un1awfuPt-o1,aIier1orj�d6 an�,.` Ii the, pernift.:;oritoldota� NVork�6��th�,,rr�iLin-'sew,�r'orlits'a�pd�t'endii�'i ie-'e�e"t"t-o#1n,
:s�ru. tpe� pip�M�foj,thei wye. - !
�t r %than, Is -:provided' for.'in'. Y11-1.
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.......... ... �,:Date..+-i.*;.` ........ ...................
APPROI
Date. . .. ...... ..... :7:24 .... .... ..... .. . ......................................... ...... ............... ..........
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The City of Edmonds
OWNER
JOB ADDRESS 001 -40
---------------- ----- ----------
APPUCATtON
for
SIDE SEWER PNMff
NEW CONSTRUCTION 13
EASEMENT NO - ---------------
R�EPAIRS El LID NO. -AZ9 ----- - ASMT. NO.,jgfo-0-
---------- CONTRACTOR �!T", NO.
------ LEGAL DESFrRIPTION: LOT NO - --------------------------------- ---- BLOCK NO - ---------- -------------------------
........... -----------------------------------------------------------------------------------------------
NAME OF ADDITION ............................................
Approved:
D,7 - ------ ----------------- ..... I
�X
--------- -
El 231IAqjA
140ffA:)IJqIA
101
TIM93q 23W32 3012
0 KOMDUAT640-) WaZ
TIMac ROTDAATKOD
------- --- -------------- .014 xooia ------- ------- ----------- OK TOJ :ZOITqIAD?,-q(J,,fADJT
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"City of - Edmonds
-CON
RIGHT -OF -MAY STRUCTION
PERMI Permit Number.
e4T
Issue Date.
A. Address or Vicinity of Construction: 23040 75 Av W (9428370)
9 0 1 9 C� B. Type of Work (be specific): Install New Servi le -
C. Contractor: Washington Natural Gas Compaay Contact: Frank iin
Mailing Address: 815 Mercer St. Seattle, VAPhone:,--.-. 224-2278
State License #: 98111 Liability Insurance: Bond:$
D. Building Perriiit # (if applicable)� Side Sewer Permit # (if applicable):
E. n Commercial Subdivision El City Project [A Utility (PUD, GTE, WNG, CABLE, WATER)
Multi -Family Single Family El Other
INSPECTOR: INSPECTOR:
F. Pavement or Concrete Cut [E Yes E]No G. Size of Cut: 1 (2 x-4) H. Chargd $
APPLICANT TO READ AND ��G
N
U44INDEMNITY.- Applicant understands and by his signature to this application, agrees to hold ityofEdmond harmle9s I m�ges, or
U 4d
claims of any kind or description whatsoever, foreseen or unforeseen, that may be made against. t4 Ibity of, dmo s, or any of its departments or
employees, including or not limited to the defense of any legal proceedings including defen8e`cost8;-aEd attorne fees byredib"nofg'�r'
_:antingthisp.ermit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS F04--A P," OF ONE YEAR �636111IYG-AWPINAL
INSPECTION AND ACCEPTANCE OF THE WORK. ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREETJI�ATCH
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.
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. J
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 thepermitivillbe
available on site at all times foL4*WTPectton pyrposes.
Signature: N�-4- - Date: September 12, 1994
(Contractor or Agent)
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY: \r, RIGHT OF WAY DEPOSIT
TIME AUTHORIZED': VOID AFTER' k1Q\J 20 DAYS. DISRUPTION FEE/FUND III:
SPECIAL CONDITIONS: RESTORATION FEE:
PERMIT FEE:
TOTALJFEE: 30 00
COMMENTS: RECEIPT FEE:
9
t 'V
DATE: ISSUED BY -
NO WORK SHALLBEGIN PRIOR TO PERMIT ISSUANCE
Engrg. Div. 1991
FIELD INSPECTION NOTES
I Comments:
I Diagram:
r, - 7 1..
(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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Pubmitted bys P1,TCMkLL, S.
Sh
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Ural: Gas
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VNC; to window
Water 3main depth
gas 3main
Key:
-w- water
�9- gas -
-ss- sewer
-e- watex hyclramt
C) . wa.tc-,.;: vb-j-ve
WA S IJ) 11 %1206) 622.--767