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23704 80TH CT W
ADDRESS:-;2-370L/ - 7074el , 0
TAX ACCOUNT/PARCEL NUMBER:
BUILDING PERMIT (NEW STRUCTURE):
COVENANTS (RECORDED) FOR:
k7-7-7 00--=,L0
CRITICAL AREAS: 4:)a - Z�j ( 63 =G0,,DETERMINATION: D Conditional Waiver r-1 Study Required M Waiver
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DISCRETIONARY PERMIT
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
PERMITS (OTHER):
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED:
SEWER LID FEE
SHORT PLAT FILE: LOT:
SIDE SEWER AS BUILT DA
SIDE SEWER PERMIT(S)
SOILS REPORT DA
STREET USE / ENCROACHMENT PERMIT
WATER METER TAP CARD DATED:
OTHER:
LID #:
BLOCK:
LATEMP\DSrs\Fonns\Street File Checklist.doc
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Address of
PERMIT NO: 9917.
'City Of Edmonds
SIDE SEWER PERMIT PE . RMIT EXPIRES_WZ6Z
Property Tax Account Parcel'No.
Attach copies of all access and utility easements Verified and Approved by
Owner and/or Contractor: L/I k Ida is Z"
Contractor Li .'Cense #:
eSingle Family
Fj Multi -Family (No. of Units
'F-1 Commercial (No. of Units
El Public
x?
ilding Permit 7
Invasion into City *Right -of Way: 0 Yes 21<0
*RW Construction Permit
Cross other Private Property: 0 Yes ETN.O.
"Attach legal description and copy of recorded easement.
Owner/Contractor ly,
t,wner or contractor signate and acknowledgement statement: Date
y signing for this permit certify that I have read the City's public handout entitled
ide Sewer Specifications, and shall comply with all City requirements outlined therein.
9 CALL DIAL -A -DIG (1-800-4244.5555) BEFORE ANY EXCAVATION 2
.9 FOR INSPECTION.CALL 425-771-0220 extension;
24 HOUR NOTICE REOUIRED FOR ALL INSPECTION REQUESTS
t� PERMIT MUST BE POSTED ON JOB SITE
-White Copy: File Green Copy: Inspector Buff Copy: Applicant
L-,temp;bldg;forms;sspennitjlg4/00
3" AB'U'
Zdeep
6" Wo
@b grade
6"wye rolled -up
45' Bend
Ademomp—x hN.-
C, f E.Djo, CITY OF EDMONDS SIDE SEWER AS- BUILT I
A D D R EU,',
23704 000th COURT SW
CONTRACTOR
Cajun
HOMEOWNER Viking Properties Inc.
I,.,(;ALE
NTS
DATE DRAWN PERMIT
6/3/2005 BY Nima M.Moghaddam NO. 9917
Scme cs:
Lot#1 6-237,
Lot#1 4— 237'
A Of
E.D,i4,_
WITH TRACER
@ 2' DEEP
CITY OFEDMONDS WATERLINE AS —BUILT
ADDRESS HOMEOWNER
23704 80TH COURT SW VIKING PROP.
CONTRACTOR
CAJUN EXC.
DATE
7/26/05
DRAWN
BY 1. ABILA
SCALE
NTS
WATERLINE
NO, 2004-1017
P!-r-
City of Edmonds
Development Services Department
Planning Division
Phone: 425.771.0220
Fax: 425.771.0221
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:-'31 f
City Receipt#:_ 1
Critical Areas File #: oc'-3-002-0
Critical Areas Checklist Fee: , $45.00
Date Mailed to Applicant: z/—//-0,3
A property owner,. or his/her authorized 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, topography map, etc.) or
studies in conjimction with this Checklist to assistant staff
in completing their preliminary assessment of the site.
The undersigned applicant, and his/her/its heirs, and assigns, in consideration on the processing of the application agrees
to release, inderrmily, 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 furnished by the applicant, his/her/its agents or employees.
By my signature, I cer* that the information and exhibits herewith submitted are true and correct to the best of my
knowledge and that I am authorized to file is plicabo f owner as listed below.
11 s
f
tox,
SIGNATURE OF APPLIcANT/AG-,- DATE
Property Owner's Author' atilo;
By my signature, I cert*i� I C authorized the above Applicant/Agent to apply for the subject land use application,
and grant my permission for e 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.
SIGNATURE OF OWNER
Owner/Applicant:
I —
DATE
PLEASE PRINT CLEARLY-..
"06� '� _) /
14ame I
�� 1; C3 Z
Street Address
6��wOJV405 f&-71>Z ell
city State zip
Telephone:
Email address (optional):
Applicant Representative:
/"�,
Name
/ -7Z 1 HC;4-'I 7T— /4z/-;-
Street Address
6;41&r e,7T— 421,
city State zip
Telephone: �T - 7-570 - 26:52-
Email Address (optional): ohry o 4 P-b i
Critical Areas Checklist.doc/3.19.2001