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PLANNING DATA
— L k -
SITE ADDRESS:
PROJECT DESCFF
REDUCED SITE PLAN PROVIDED?(I�/ No)
MAP PAGE: Q t-pffp CORNER LOT: Ms / No FLAG LOT: (Yes / No
Z0NING:0,',Z-,-S —CRITICAL AREAS DETERMINATION #.�CA Oa
Study Required:
'�Wwalver
.0 Conditional Waiver
SEPA DETERMINATION:
U Fee
Checklist
APO list w/ notarized form
L3 (Needed for 500 cubic yards of grading, Shoreline Area- site within 200 ft. of P . u go . t . Sound or Lake Ballinger)
Exempt
SETBACKS:
Required Setbacks: I
Street; gn Left Side: 'I. Right Side: -7 Rear:
Actual Setbacks:
LeftSIde: -1 Right Side: -7 Rea ��(4
Street: 8a r:,
Street map checkkeB'for additional setback required? (Yes/No/DNA)
Q DETACHED STRUCTURES:
El ROCKERIES:
U FENCES/TRELLISES:
UBAY WINDOWS / PROJECTING MODULATION:
Q STAIRS I DECKS:
PARKING: Required: ZI Actual: 7�: 2—
LOT AREA: _'-1 Le I tv
I ^Ir . � C'I -7
cof
0 '7
BUILDING HEIGHT: 1 0
Datum Point:1 C� I 'IT N-k U Datu Elevation: I CDQ A I
M aximum Allowed: ualHeight:
41
A.D.U. CREATED?(�jj Y
0:9
Jos
SUBDIVISION`-, I
LEGAL NONCONFORMING LAND USE- DETERMINATION ISSUED: (Yes I No
OTHER:
Plan Review By. �F� 1 �."La6' i I
NewBPPIanningDataFomLD0C
.10-7
C'
Cf3
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I _.X0 t__U� .
APPROVED AS NOTED
BY ENGINEERING
a- C-1 t u
Date: 1 '2-41 (jc�
A
XDD GUT��fk?�O wly's
j UP
To
Pik ou
STREET FILE
IS RESpONSISLE FOR
L AND DRAINAGE
RECEIVED
AUG 2 1 2002
BUILDING DEPT.
6 .1 -ST pt t/ 6 W,
APPROVED AS.NOTED
BY ENGINEERING
Oa.
611 ri,+
Dalte: 6yo
-? —1 -
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c 0
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7 t
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SETBACKS:
_R0M
8DE.
REAR I z
OTHER
HEIGHT-1
RIGHT-OF-WAY CONSTRUCTION PERMIT
,AND INSPECTION REQUIRED
(fee, . 0,
.r I w I
x u
(A 0 V S
PrIf I,,-;
,ry Im 41WNEFIW=�RACTOR IS RESPONSIBLE
"EROSION CONTROL -AND DRAINAGE
W kre- fl-
-)(Xol
6-�tgrlo,�-
W pwr CF/L 1-� F
v
RF—COVED
SEP 16 2002
BUILDING DEPT.
REECEIVED
AUG 2 1 Zoo2
BUILDING DEPT.
�- It) I .5T, Pt v c W,
E .7- R T-
I L E":
0
Critical Areas Checklist CAFileNo:
Site Information (soils/ topography/ hydrology/ vegetation)
1. Site Address/ Location: :R-':V-jj Ave -- r
V E�ncwc&
2. Property Tax Account Number: 1/1/,/, /-:5
3. Approximate Site Size (acres or square feet):
4. Is this site currently developed? 4 yes; — no.
If yes; how is site developed?
5. Describe the general site topography. Check all that apply.
Flat: less than 5-feet'elevation ch over entire site.
�ange
Roffing: slopes on site:generally less* than 15% (a vertical rise of 10-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 10-feet
over a horizontal distance of 33 to 66-feet).
Steep: grades of greater than 30% present on site (a vertical rise of 10-feet over a horizontal
distance of less than 33-feet).
Other (please describe):
6. Site contains areas of year-round standing water: J.-) Approx. Depth:
7. Site contains areas of seasonal standing water: Approx. Depth:
What season(s) of the year?
8. Site is in the floodway Ja floodplain jjn of a water course.
9. Site contains a creek or an area where water flows across the grounds surface? Flows are year-round?
- &L Flows are seasonal? . I (What time of year?
10. Site is primar�ly: forested _ ; meadow ;shrubs mixed
urban landscaped (lawnshrubs etc). ." " '' ! '-.
V
11. Obvious wetland is present on site: U1, " -7—
N -Nr",
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Critical Areas Checklist.doe/3.19.2001
City of Edmoim'ds.'
Development Services Department,,
WPlanning Division
Phone: 425.771.0220
'10,1891� Fax: 425.771.022 1
The Critical Areas Checklist contained on this form is to
be filled out by any person preparing a Development
Permit Application for the City of Edmonds prior to
his/her submittal of the application 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).
Date Received: AP -2
City. �eceipt M
Critical Areas File M.
Critical, Areas Checklist'Fee: $45.00
D�ate'Mailed -to Applicant:
A property owner,,or his/her authorized repre�entative
must fill out the checklist, sign and date- it, and submit it
to the City. The City wilLreview 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
s I pecific' ece d escribed on this form. hi
pi property d'
addition, the applicant shall include other pertinent
information (e.g. site plan, topography map, etc.) or
studies in conjunction with this Checklist to assistant staff
in completing their preliminary assessment of the site.
The undersigned applicant, and hisfher/its heirs, and assigns, in consideration on the processing of the application agrees
to release, indemnify, defend and hold the City of Edmonds harmless from any and all damages, including reasonable
attorney's fees, arising from any action or infraction based in whole or part upon false, misleading, inaccurate or
incomplete information famished by the applicant, his/her/its agents or employees.
By my signature, I certify that the information and exhibits herewith submitted are true and correct to the best of my
knowledge and that I am authorized to file this application on the behalf of the owner as listed below.
SIGNATURE OF APPLICANVAGENT I'X
A,�, DATE
Property Owner's Authorization
By my signature, I certify that I have authorized the above Applicant/Agent to apply for the subject land use application,
and grant my permission for the public officials and the staff of the City of Edmonds to enter the subject property for the
purposes of inspection and posting attendant to this application.
6,2
SIGNATURE OF OWNER DATE
Owner/Applicant:
7�_ R
Naine
Applicant Representative:
PON - �, �10�r �d Z�11�0
(�� :� 3 4 11 1 (2 12- A,,,- 13
S�e`et Addre-ss'' Street Address
City State Zip City State Zip
Telephone:
Email address (optional):
Telephone: Z'
Email Address (optional):R, E C F. ; V F7 n
Critical Areas Checklist.doc/3.19.2001
M.-AY - 2 2002
PE-RNTf COUN'T-E-Pi
FPERMIT EXPIRES
CITY OF EDMONDS
USEE PERMIT
ZON
NUMBER
CONSTRUCTION PERMIT APPLICATION
Joe SUITE/APT#
ADDRES:_�' _ /"#?/ _��F
_qal�l 4-11
OWNER OF BUSI7'(7
/�ME
07--/
PLAT NAMEISUBDIVISION NO.
I LOT NO, Ull
NO,
MAILING ADDRESS
-73 3 57 _S0
LID
FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TES
S_
EXISTING— PROPOSED—
Si,1
REQUIRED DEDICATION— FT
F App,0 13
� R�i, 0
U.- %. CI
P-uir. a
R—.
C" ZIP
JITELEPHONE
NAME
METER SIZE
LINE SIZE
NO. OF FIXTURES I
PRV REQUIRED
I
I
YES 13 NO 13
z
t. ADDRESS
REMARKS
z
x
Lit
OWNEWCONTRACTOR RESPONSIBLE FOR EROSION CONTROLID RAIMAGE
CITY ZIP
TELEPHONE
NAME
CBL'
Lf�
ENGINEERING REVIEWED BY DATE
ADDRESS
0
FIRE REVIEWED BY DATE
CITY ZIP
0
TELEPHONE
STATE LICENSE NUMBER EXPIRATION DATE
CHECKE0 BY
VARIANCE OR CU
I SH OREUNEORADB#
1,,INSPECTION
YESECISNO
BOND
POSTED
$
< PROPERTY TAX ACCOUNT PARCEL NO,
(o) (n)
SEPA REVIEW
COMPLETE EXEMPT
EXP
SIGN AREA
ALLOWED I PROPOSED
HEIGHT
ALLOWED I PROPOSED
NEW RESIDENTIAL [3 PLUMBING I MECH
LOT C VERA E
OWED 0 PROG
ALL POSED
RED IRED SETBACKS (Fr.)
U
FRONT SIDE REAR
PROPOSED SETBACKS (FT.)
FRONT UR SIDE REAR
a
C MPLIANCE OR
ADDITION COMMERCLAL 11 CHANGE OF USE
REMODEL MULTIFAMILY 13 SIGN
z
z
RKING
RE0ffpA I PROVIDED
LOT AREA
PLANNING REVIEI�ED BY DATE
Ei F NCE
REPAIR GRADING CYDS X_ FT)
REMARKS
DEMOLISH C] TANK OTHER
Ei GARAGE RETAINING WALL C:] FIRE SPRINKLER
CARPORT ROCKERY FIRE ALARM
(TYPE OF USE. BUSINESS 0. f-- EXPLAIN:
AJ r—;�l L I
CHECKED BY ITY7
F CONSTRUCTION
'e
ICODE OCCUPANT
q7 GROUP
NUMBER
OF .
' 0 STORIE a
IN 13ER OF
T UM
I DWELLING
UNITS
z
CRITICAL 4�Z
AREAS e
NUMIE
a PECIALINSPECTIbN
R EQU�RED
JAREA OCCUPANT
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
20
PROGRESS INSPECTIONS PER UBC I 08/FINAL INSPECTION REO'D
0', F-1,2 F /D111111191,P?
L)A,'i qr- If—
VALUATION
Deecription
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE % Bwlq�pg Permit City Surcharge
PLAN CHECK VESTED DATE
7." Plumbing
IV _
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
j= 13E DOME ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
00 MAIN (CURBS, SIDEWALKS, DRIVEWAYS MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PEIRM;SSION.
Engr. Review
PERMITAPPLICATION: IBODAYS
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'AP LICANT ON BEHALF OF HIS OR HER SPOUSE. HEIRS ASSIGNS AND SUCCESORS Fire Review Plan Chk. Deposit
1111IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS. WASHINGTON. ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND Fire Inspection Receipt #
. ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY V71a I
x FROM THE ISSUA CE OF THIS PERMIT ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY. WAIVE OR REDUCE ANY REOUtREMENT OF ANY ORDINAN E Landscapelnsp. Total Amt.
CITY 0 Due
0 NOR LIMIT IN ANY WAY THE C"S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.1 Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPUrATION: THAT THE INF RMATION
GIVEN IS CORRECT�, AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF APPLICATION APPROVAL
THE OWNER. I AGREE TO COMPLY WITH CRY AND STATE LAWS REGULATING CONSTRUC. This application is not a pertnit unid signed by the
TION: AND IN (>DING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED CALL Building Official or his/her Deputy; end Fees are paid. end
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTI 0 N ..lot is aCkruwriedged in space provided.
WORKMEN'S C?!;ENSAT1qI)I INSURANCE AND RCW 10.27.
OFFICIALS Sp. 'ATURE I DATE
SIGNA �j;.�V-�ERAGE DATW; (425)
77 RE�E BED BY /DATE
Arr`TEN�ZN EM 1333 �' 1�.' ,
:7))
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL 08 A CERTIFI-ORIGMAL-FILE YEU_CW-fNSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK -OWNER GOLD -ASSESSOR
G4/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER Nf�"E OF BU13IN
P) M/
tf �_
r
MAILING ADDRESS
73 3 /&/Enr
CITY ZIP TELEPHOit�t/,Z,
902- It
qL�L�
NAME
CITY
CBL
NAME__,:,,�.. _... - "A
=V\
ADDRESS
A149
PERMIT EXPIRES
USE PERMIT
ZONE
NUMBER
JOB
ADDRESS
suAFr#
PLAT NAME/SUBDIVISION NO.
LOT NO.
LID No.
LID E I
;LA
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
..0 ".ed
RW Permit Required
Street Use Permit Wd
EXISTING PROPOSED
inspection Required
Sidewalk Required 13
REQUIRED DEDICATION— FT
Underground
Widn-a required 13
METER SIZE
LINE SIZE
NO. OF FIXTURES
PR�VREOUIRED
=13NO
YES 13
z
22
REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROWDRAINAGE
z
3
a
v
FIRE,,. REVIEWED BY
DATE
us
cc
rL
CITY
ELEPHONE
VARIANCE OR
SHORELINE -OR ADB��'I,,'
INSPECTION
�REO`D
' ONO
13YE9
BOND
POSTED
$
EXPIRATION
STATE LICENSE NUMBER I` I/ - .1
CHECKED BY
1 ,
SEPA REVIEW
COMP LETE -EXEMPT
SIGN AREA
ALLOWED PROPOSED
HEIGHT
-A�LOWED PROPOSED
PROPERTY TAX ACCOU NT,
I
EXP
LOT COVERAGE'
REQUIRED SETBACKS (Ft.
',REAR
.,'R6POSED SETBACKS (FT
-,P
NEW
RESIDENTIAL
PLUMBING MECH
L PROPOSED
ALLOWED
FR ONT SIDE
FRONT', URSIDE REAR
z
ADDITION
N[:] COMMERCIAL
COMPLIANCE OR
0 CHANGE OF USE
DATE
PARKING
LOT AREA
LANNING REVIEWEO,SY
13 REMODEL
MULTIFAMILY
SIGN
P
RE ROVIDED
IP
0 REPAIR
FENCE
GRADING CYDS X FT)
REMARKS
TANK
o OTHER
DEMOLISH
GARAGE
CARPORT
RETAINING WALL - 0. FIRE SPRINKLER
ROCKERY FIRE ALARM
(ME OF USE. BUSINESS OR ACTIVrM EXPLAIN:.,'
CHECKED BY, ]TYPE.OF
C TR�UTI ON
54' -7
OCCUPANT
OUP
GR K3
S1tkAI__1*
NUMBER
NUMBER OF
DWELLING,
CRITICAL
AREAS
SPEC IAL INSPECTION
OCCUPANT
LOAD
OF
STORIES
UIRM
NUMBER
JAREA
REQUIRE , D . [] YES
DESCRIBE WORK TO BE DONE
REMARKS
MnI.i:4
PROGRESS INSPECTIONS7PER USCAOS/FINAL INSPECTION REaD
cn
A.
VALUATION
Descrioilo'n
,jFEE
Description
FEE
Plan Check f,J
State Surcharge
HEAT SOURCE
ULAZINLilb
Build!
Lxy burcriarge
A
1�"PlurnbrhgY
W
PLAN CHECK NO:
VESTED DATE �v
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DOME ON PRIVATE PROPERTY ONLY. Amy CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMITAPPLICATION: ISO DAYS
PERMIT LIMIr I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
Fire Review
Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFX DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
E
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
9 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
Landscapelnsp.
Total Arnt Due
0 THE CrrY`S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
NOR LlMrF IN ANY WAY
Fee
Receipt III
r
Recording
I HERE13Y ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
APPLICATION
APPROVAL
by the
GIVEN IS CORRE"
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
CALL
This application Is not a permit until signed
Building Official or his/her Deputy: and Fit as are pald,.and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
rect6 ackq6;kdged In space provided.
WORKMEN'S Spk�TION INSI)PANCE AND RCW 18.27.
FI LS DATE
SIG E
DATE SIG D
It —
IA05)
%-WK-
-
&7;lcm
�WER'
7 7
771-0220
f DATE
AITE14TION(/
M 1333
zi�j� 6161-di
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL - FILE - YEI I ON - INSPECT&
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
PINK -OWNER - GOLD -ASSESSOR
HARD -YOU ARE MAKING 5 COPIES
GREEN - ACCOUNTING
04/02 PRESS I
City of Rdm onds Permit No:
RIGHT-OF-WAY CONSTRUCTION PERMIT Issue Date:.q 17S 7
A. Address or Vicinity of Construction: I o I S-r ryAw
B. Type of Work (be specific
M
C. Contractor: �e-
� ao
r
Contact: Vt J ( e ) 00 7- 7-
Mailing Address:.)-1 Mptv,)
X'320 KfA A)k V673 Phone: lr2S-
State License
Y"o 3 P 7-
Liability Insurance: Bond: $
D. Building Pertf�it (if applicable):
Side Sewer Permit # (if applicable):
E. r-1 Commercial
Subdivision
El City Project EUC (PUD, VERIZON, PSE, AT& T, OVWD)
F� Multi -Family
Single Family
E] Other
INSPECTOR:
F. PAVEMENT CUT: El YES In NO G. SIZE OF CUT x
CONCRETE CUT: El YES JKI NO
ANIACANTTO 1U`,1Al) ANI) SICN
INDEMNITY: Applicant understands by his/her signature. to this application helshe holds the* City of Edmonds harmless ftom
injuries, damages or claims of any kind or description whatsoever, foreseen or unforeseen, that may be mad� 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 and attorneyfees by reason ofgranting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOHING THE FINAL
INSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES W1LL BE HELD UNTIL THE FINAL STREET PATCH IS
I
COMPLETED BY CITY FORCES, AT WHICH TIME A DEBIT OR CREDIT W1LL 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
I HA VE READ THE ABOVE STATEMENTS AND UNDERSTAND THE PERMIT REQUIREMENTS AND ACKNOWLEDGE
THATIM:U:SXTMAKETH. PIN OPY OF THE PERMITA VAILABLE ON SITE A TALL TIMES FOR INSPECTIONS
Signature: Date:
(Contractor oir Agent)
FORCITYXSE ONLY
-of w
Approved by: A I 1_A9,KT_ Right ay,, Fee:
Time Authorized: Void After 1_5�k `63 .,Disruption Fee/Fund Ill:*
Special Conditions: Restoration Fee:'
Total Fee:.
Receipt No:
Issued by:
UPON COMPLETION OF PERMITTED WORK, AN ENGINEERING FINAL
INSPECTION IS REQUIRED PER CHAPTER 18.00 OF THE EDMONDS
COMMUNITY DEVELOPMENT CODE (Phone 425-771-0220, Ext. 1326)
FINAL APPROVAL OF PERMITTED WORK. DATE:
Inspector's Signature
For inspection requirements see Engineering Inspection Information handout.
= ... . ...... ..
NO WOIZK SI-IAI-,L BF,GIN I'lZ101Z TO 1'l',1ZM1T ISSUANCE
DAMy Documents\Forms\Engnmg\ROWpermit Am
Permit
CitY of ECfionds
RIGHT-OF-WAY CONNkUCTION PERMIT
A. Address or Vicinity of
B. Type of Work (be specific
Issue Date:aJZ�;J()7
_ L__
C. Contractor:_ 4t1(dE-- -)(Tol-7- Contact: ill 'J rr
Mailing Address:-)Ll /VIA-,,' `320 K,(lz �Sd,73 Phone: ,Is -
State License #:
7 �' Liability Insurance: Bond: S
D. Building Permit # (if applicable):_
E. D Commercial El Subdivision
El Multi -Family
INSPECTOR
El Single Family
lcmnefl I C.,
F. PAVEMENT CUT: YES 8 NO
CONCRETE CUT: YES 91 NO
Side Sewer Permit # (if applicable
EJ City Project [I EUC (PUD, VERIZON, PSE, AT& T, OVWD)
El Other
G. SIZE OF CUT x
INDEMNITY: 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 and attorneyfees by reason ofgranting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOFffNG THE FINAL
INSPECTION AND ACCEPTANCE OF THE WORK. RE RA Wt I
COMPLETED BY CITY FORCES, AT EST'MA TED STO TION FEES LL BE HELD UNT L THE FINAL STREET PATCH IS
WHICH TIME A DEBIT OR CREDIT JnLL BE PROCESSED FOR ISSUANCE TO THEAPPLICANT.
# 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.
4 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
I HA VE READ THE ABOVE STA T TAND THE PERMIT REQUIREMENTS AND ACKNOWLED E
THA T I MUST MA KE T G
Y OF THE A VAILABLE ON SITE A TALL TIMES FOR INSPECTIONS
Signature:
-W , . '/ Contractor or Agent) Date:
Approved by: FOR CITY US
C,�] (LA GR T- 0� ght-of-way Fee: '10 f— 4�-
Time Authorized: Void AfteraPiVy--s- Disruption Fee/Fund 111:
Special Conditions: m4
Restoration Fee:
Total Fee:
Receipt No:
Issued by:
UPON COMPLETION OF PERMITTED WORK, AN ENGINEERING FINAL
INSPECTION IS REQUIRED PER CHAPTER 18-00 OF THE EDMONDS
COMMUNITY DEVELOPMENT CODE (Phone 425-771-0220, Ext. 1326)
FINA L A PPR 0 VA L OF PERMITTED WORK.. Inspector's Signature DATE: —
For inspection requirements see E
Inspection Information handout.
DAMY DocumcnisTorms\Engnmg\RoWpermit—.doc