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23706 74TH AVE W
ADDRESS: 9-�3q 06 — -�j4v hj� yj
TAX ACCOUNT/PARCEL NUMBER: 00-14H&- 606-00q -() /
BUILDING PERMIT (NEW STRUCTURE):
COVENANTS (RECORDED) FOR: AN 3 WWI,
.", — / 2� -
CRITICALAREAS: '41') DETERMINATION: E] Conditional Waiver E]StudyRequired >(Waiver
DISCRETIONARY PERMIT
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
PERMITS (OTHER): Za) Z -C)q,7 Z CAW L�tjf Igg,11-6651 /-y&�
PLANNING DATA CHECKLIST DATED: -/d AlIq
SCALED PLOT PLAN DATED: /0/9/-? -7
SEWER LID FEE LID #:
SHORT PLAT FILE: LOT: BLOCK:
SIDE SEWER AS BUILT DATED:-iq// 0/0 3 IUD SIDE SEWER PERMIT(S) #:
SOILS REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
FOR:
WATER METER TAP CARD DATED:
OW(6-rf,) q5-IL17,
OTHER: �0 w (em,9 �cvvl
LATEMP\DS'rs\Forms\Street File Checklist.doc
DATE RECEIVED m o
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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MAILING ADDRESS
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CITY ZIP TELEPHONE
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CITY ZIP TELEPHONE
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NAME ICBL#
ADDRESS
USE
ZONE
JOB
ADDRESS
PLAT NAME/SUBDIVISION NO.
PERMIT
NUMBER,��V_
LID NO.
LID FEE $
TEScF APPMW
RW Perfralt Required
Street Use Pamift ReV
hupection Required 13
Sidewaik Required 13
Underground
Wiring required 13
PRV REQUIRED
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YES 13 No It
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REMARKS z
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
IF
FIRE REVIEWED BY 41 DATE ILI
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LOT NO.
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING — PROPOSED
REQUIRED DEDICATION— FT
METER SIZE I LINE SIZE OF FIXTURES
VARIANCE OR CU SHORELINE'6R ADB# INSPECTION
-CHECKED BY
STATE LICENS'E NUMBER EXPIRATION DATE
71.13YASEOLINO
SEPAAEVIEW,:-.'._,
COMPLETE, '.EXEMPT.-�',
SIGN AREA V
-ALLOWED 'PROPOSED
PROPERTY TAX ACCOUNT, PAAdEL NO. o
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-FRON7 SIDE',.REAR
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PLANNING REVIEWE
REMODEL MULTIFAMILY SIGN
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REMARKS
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FIRE SPRINKLER
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(TYPE OF USE, BUSINESS OR ACTIVU"Q EXPLAIN.
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NUMBER
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NUMBER OF
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SPECIAL INSPECTION
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DESCRIBE WORK TO BE DONF
REMARKS--'
PROGRESS INSPECTIONS PER UBC 108/FINA
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VALUATION
$
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BOND
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FRONT UR SIDE REAR
DATE
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Description
:. .- ��FEE
Description
FEE
Plan Check 101�4
State Surcharge
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HE&ME GLAZING % OPE %
71
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City Surcharge
PLAN diECK Nng_ (/9-7 VESTED Dktfi
NUMbingr
THIS PERMrr AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
I= BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
U
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: 180 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 INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
I
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
i
Fire Inspection
- Receipt #
x ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY; WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
Landscapelnsp.
Lan
Total Amt. Due
0 NOR LIMIT IN ANY WAY THE CIIYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.,
x
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Recording Fee
Rec,
Receipt #
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 ,QDE OF THE STATE OF WASHINGTON RELATING TO
01
FOR INSPECTION
A receipt's a cknovAedged In space provided.
WORKMEN'S COMPENSAT��ffE AND RCW 18.27.
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IT TO USE OR OCCUPY
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IS UNLAWFUL A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
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CATE OF OCCUPANCY HAS BEEN GRANTED. ' BC SECTION 109
ORIGINAL - FILE YEI I ON - INSPECTOR
PINK - OWNER GOLD - ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
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USE PERMIT
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OWNER NAME/NAME OF BUSINESS
GAL DESCRIPTION CHECK SUBDIVISION'NO.
LID
NO.
"ILING ADDRESS
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved 0
EXISTING —REQUIRED DEDICATION
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CITY ZIP 1,—TELEPHONE
NUMBER
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REMARKS
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TELEPHONE NUMBER
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TELEPHONE NUMBER
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STATE LICENSE NUMBER E�PIRATI N DATE
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VARIANCE OR CU
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SHORELINE #
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Legal Description of Property - include all eas6ment
HEIGHT
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SEPA REVIEW
COMPLETE EXEMPT
SIGN AREA
ALLOWED PROPOSED
ALLOW ROPOSE
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EXP
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LOT COVERAG E
REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (FT.)
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ALLOWED PROPO SED
FRONT SIDE REAR
FRONT UR SIDE REAR
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Property
Tax Accoun
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LOT AREA
PL-ANNING fEDEW BY
DA�E (L
16157F 2
Parcel No.
REMARKS
NEW [R-RESIDENTIAL ECH
COMPLIANCE OR
2rADD,T,ON 0
COMMERCIAL CHANGE OF USE
BREMODEL 1:1 APT. BLDG. El SIGN
HECKED'BY
TYPE OF CQNSTtqUCTION
7CODE
OCCUPANT
GRADING FENCE
FIREPAIR 1:1
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GROM
— CYOS. ( x —FT)
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T SWIM POOL
DEMOLISH F] WOODS OVE F
INSERT HOT TUB/SPA
SPECIAL INSPECTOR
AREA
OCCUPANT
LOAD
REQUIRED
1:1 YES
M-0 I,=
FGARAGE RETAINING WALL/
TARPORT ROCKERY R ENEWAL
REMARKS
PROGRESS INSPECTIONS PER UBC 108
OF USE, BU SINESS OR ACTIVITY) EXPLAIN:
(TYPE
Ir
�f2 13 h2r,- kill&o.
NU MBER
NUMBER OF
CRITICAL
W
OF
DWELLING
i,
AREAS
INUMBER
STORIES
UNITS
OLD 'r-
DESCRIBE WORK TO BE DONE (ATTACH PLOT PLAN)
FINAL INSPECTION REQUIRED
VALUATION
FEE _11100�m
0
PLAN CHECK FEE
7111 7-
BUILDING
311
H�T SOUR�C�:
GLAZING
PLUMBING
Plan Check No.
MECHANICAL
i
wit
This Permit covers work to be done on private property ONLY.
GRADI NGIFILL
Any Construction on the public domain (curbs, sidewelks,
.
driveways, marquees, etc.) will require separate ion.
STATE SURCHARGE
-permiss
Permit Application: 180 Days
STORM DRAINAGE FEE
Permit Limit: I Year - Provided Work Is Started Within 180 Days
"Applicant, on behalf of his or her spouse, heirs, assigns and
ENG. INSPECTION FEE
successors in interest, agrees to indemnify, defend and hold
harmless the City of Edmonds, Washington, its officials,
employees, and agents from any and oil claims for damages of
X
whatever nature, arising direct ly or indirectli,,from the issuance
---
-7.
of this permit. Issuance of this permit shallinot be deemed to
PLAN CHECK DEPOSIT
modify, waive or reduce any requirement Of any city ordinance
0
nor limit in any way the City's ability to enforce any ordinance
TOTAL AMOUNTPUE
provision."
I hereby acknowledge that I have read this application; that the
ATTENTION
APPLICATION APPROVAL
information given is correct; and that� '.1 am the owner, or the duly
authorized agent of the owner. I agree to comply with city and
laws construction; a�� in doing the work authoriz-
THIS PERMIT
AUTHORIZES
This application is not a permit until
state regulating
ed thereby, no person will be employed in violation of the Labor
ONLY THE
WORK NOTED
signed by the Building Official or his/her
Deputy; and fees are paid, and receipt is
Code of the State of Washington relating to Workmen's Compensa-
.
acknowledged in space provided.
tion Ins urancei6'rid ELC)�'18.27.
I NSPECTION
S�GNATURE (OwqER Oq AGENT) ATE SI N
PEPARTMENT
OFFICIAL? SIGN,#, URE DATE
0-3 -97
CITY OF
EDMONDS
z/
CALL FOR
REI_Ek�gb By*
ATTENTION
INSPECTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR
771-0220 ORIGINAL — File YELLOW — inspector
A CERTIFICATE OF OCCUPANCY HAS. BEEN GRANTED. UBC
PINK — Owner GOLD Asses$oF___-
SECTION 109
0/ .5,
u749EET F L
(D �D.
USE PERMIT
CITY OF EDMONDS ZONE NUMBER -94 065 1
CONSTRUCTION PERMIT APPLICATION ,.
OWNER NAMEINAME OF BUSINESS ]ICATION ADDRESS 70 c, 14-4 '46),e- ir/APT
M%L!I,AP-CL Au,4110 CAa,34!�,-, VJa0OS LEGAL DESCRIPTION CH?M��O. LID NO,
MAILING ADDRESS i.., .1.1
7-3106 -14'6 A-44C vi PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP. TESCP APPfoved "10
U;r FIW PI -it Required
CITY ZIP ItLtr`HUNENUMeER EXISTING — REQUIRED DEDICATION of
Street Use P*,.iI R04-d 0
tot0 nto, I F4 C% PROPOSED
NAME Sidewalk Required 0
METER SIZE I LINE SIZE I NO. OF FIXTURES PRV REQUIRED
.... ES 0 NO
2�� iit!!�
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CITY ZIP---7TELEPHONE
NUMBER
A xp 14., � e po
N E
r`24
ADDRESS
l,qCC ja — &7t�- X) - e=— 1
.N GN
ENGINEERING MEMO DATED
E
7 / 5 �1(74-
CITY
Aeu,loe,-7ne) 981W
1 —750
FIRE MEMO DATED
IFIE -El
ETE LICENSE NUM13ER
EXPIRATION DATE
SIGN AREA
ALLOWED PROPOSED
4;
SEPAREVIEW
COMPLETE , JEI�
1EXP
Legal Description of Property - include all easements
44 1.�
VARIANCE OR CU
L 0 BY
i '" r� 1151544 1
ETBACKS — FEET
S 5 T.
o FRONT /9.; 6SIDE '7VL REAR /6
EIGHT L
'10
I at ACC0111111
Parcel No. W6, aos . 00 4 - 01 Q-3
NEW RESIDENTIAL PLUMBING
ADDITION COMMERCIAL MECHANICAL
ElREMODEL APT. BLDG. SION
GRADING FENCE
EIREPAI. CYOS. x _FT)
GODSTOVE .0 sw OOL
0 DEMOLISH INSERT HOITIMTP
U81SPA
GARAGE RETAINING WALL/
CARPORT LJ ROCKERY RENEWAL
0 (TYPE OF U SINESFR �CT
s�y IVI
-S
CHECKED BY
E OF CONST�UCTION CODE
—z— /o
1 T=yP 191
SPECI�L INSPECTOR JAREA
RE OU ED
ES
WMARKS
PROGRESS INSPECTIONS PER USC 305
NUMBER NUMBER OF ICRITICAL
OF ! S DWELLING AREAS `77
0 STORIE UNITS NUMBER
TO PLOT PLAN)
DESCRIBE WCA9 BE DONE (ATTACH
Aor) ?.--c_AeL GPnA&y AVo h IIE�_ K_
FINAL INSPECTION REQUIRED
VALUATION
PLAN CHECK FEE
BUILDING
HEAT SOUR
GLAZING %
PLUMBINO
Plan Check No.
MECHANICAL
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewolks,
-driveways, marquees, etc.) will require separate permission.--
GRADINGIFILL
STATE SURCHARGE
Permit Application: 180 Days
Permit Limit: I Year - Provided Work Is Started Within 180 Days
STORM DRAINAGE FEE
ENO. INSPECTION FEE
"Applicant. on behalf of his or her spouse, heirs, assigns and
c rs in interest. agrees to Indemnify, defend and hold
i.2 sharmcelesssso the City of Edmonds, Washington, its officials,
a employees, and agents from any and all claims for damages of
whatever nature, arising directly or Indirectly from the Issuance
PLAN CHECK DEPOSIT
A 7
OCCUPAI
LOAD
of this permit. Issuance of this permit shall no, be deeme to
0 modify, waive or reduce any requirement of any city ordin :nc:
Ifir JWW
I
T5 nor limit In any way the City's ability to enforce any Ord n nc
TOTAL AMOUNT DUE
provision."
som� I
C;W
I hereby acknowledge that I have read this application; that the
ATTENTION
APPLICATION APPROVAL
Information given is correct; and that I am the owner, or the duly
authorized agent of the owner. I agree to comply with city and
THIS PERMIT
This application is not a permit until
state laws regulating construction; and In doing the work authoriz-
ed thereby, no person will be employed In violation of the Labor
AUTHORIZES
ONLY THE
signed by the Building Official or his/her
Code of the State of Washington relating to Workmen's Compensa.
WORK NOTED
Deputy; and fees are paid. and receipt Is
tion Insurance and RCW 18.27:
NSPECTION
acknowledged in space provided.
IF —SIGNATURE QWNER TW DArt SIGNED 6EPARTMENT OFFICIAL' E
CITY OF
&--so _9 EDMONDS
LaZZ�� CALL Z� RELEA S
T ENTION INSPECTION
IT S UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR 1 we U;dZU ORIGINAL - File YELLOW - Inspector
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED. USC
PLANNING DATA
NAME:
SITE ADDRESS:—.2-? 7 0 (., - 7 q, � t Alt IDA T E: 1016 9 "7
ZONING: 5 —PLAN CHK#.
PROJECT DESCRIPTION:
_04a"�� L Yu-cvf
CORNER LOT (Yes/No) FLAG LOT— & -6 (Yes/No)
to
SETBACKS:
Required Set cks:0,
Fron *.,,. Left-Stde—. Right Side:__%��—" Rear:
Actual Setbac s:
Front: /0 Left Side: Right Side: Rear: to
Street map checked for additional setback required? (Yes/No)
LEGAL NONCONFORMING LAND USE DETERMINATION ISSUED (Y/N)
7 70
LOT COVERAGE:
Maximum Allowed: —Actual:,
BUILDING HEIGHT:
Maximum Allowed:
—Actual Height:
Datum Point:
—Datum Elevation:
IF 0
A.D.U. CREATED?:
SUBDIVISION:
CRITICAL AREAS#.
SEPA DETERMINATION:
LOT AREA.
OTHER:
Plan Review By: 0 cro,
cMileApeffniMplandaLdoc
Site Information
Pro ect Name:
q
Critical Areas Checklist
Permit Number:
Site Location: c.? GJfflotid,5 Property Tax Account Number:
Approximate Site Size (acres or square feet): (og :t0r,
Have you filled out a Critical Areas Check I list for a project on this site before? dc)
General Site Conditions
1. Has the site been cleared or logged? !j-P-5 Date of most recent action: (Jr11<V)0UY)
Soils / Topography
2. In the Snohomish County Soil Survey, what is the mapped soil type(sr
4Z*_
3. 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 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 of horizontal distance.)
-Steep: grades of greAter than 30% present on site.
Comments
HydrologyNegetation
4. Site contains areas of year-round standing water: /�o
5. Site contains areas of seasonal standing water. ' A&)------Approx. Depth:
6. Site is in the floodway floodplain A11-0 of a water course.
7. Site contains a creek or an area where water flows across the grounds surface? A& —flows
are year-round? Flows are seasonal?
8. Site is primarily: _f6rested meadow shrubs mixed
9. Obvious wetland is present on site:
10- Wetland inventory or map indicates wetland present on site:
11. Critical Areas inventory or map indicates any Critical Area on site:
For City Use Only
E
................
City Pf Edmonds
Critical Areas
Checklist
ac Critical Areas Checklist contained on
this form is to be filled out by any person
PrIparing a Development permit
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 PrOPartY. 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).
NZCA�', VAE. 0
1993
An aMlicant� or his/her representative, must
fill out the chccldist,'Sign and date it� and -
submit it to the City. -ne City will review
the checjdist� make a precursory site visit,
and make a determination of the subsequent
steps necessary to complete a development
permit application.
With a signed copy of this form, the
applicant should also submit a vicinity map
Of the Parcel with enough detail that City
staff can find and identify the subject
Parcel(s)- In addition, the applicant is
encouraged to include any other pertinent
information or studies. in conjunction with
this Checklist to assist staff in completing
their preliminary assessment of the site.
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 / Appli�
Icant:
Mi VJC:'0CL-5
Narne
0 37C(o - -7d7-4/A Ve-
S et Addre�ss��
WA qZ02f
CitY, State, Zip
Phone
Si ature
Date
Applicant Representative:
Name
Title
3-5-0 1KW 17J-��411
Street Address
J &71e �1177
City, State, ZIP0, Phone
Z�
, Tal-I
Signature
Date
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EOTOF- No wakmrry oF 01"AUY The information shown ontfii
Cln-r�lcd m.t,,,j was compiled for use by the City of Edmont3, i,.
The City of Edmonds does not viarrzrt
ar,�'..�:�'. s�.! forth on the map. Aqy �,�,rson or entfty req,*.,s-...,-..,j a C."')
c-,l. an independent IF,� �;;,ji r-,—�,ding the Inforid""c-n
t:,- inc'-�ing but not IL:.� location of an
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CITY COPY
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CITY CLERK
CITY OF EDMONDS
121 5TH AVENUE NO.
EDMONDS, WA 98020
STATEMENT ON ACCESSORY DWELLING UNITS
GRANTOR: 11r)1e-yHA4L 1bqzd5z910 GRANTEE: &Lkl
3706 - 74 -P�
Property Address:
Edmonds, Washington
Legal Description: fi-e- COS' D-0
T-K-5-ek-=
Assessor's Parcel Number:
I have read the requirements for accessory dwelling units contained in Chapter 20.21 of
the Edmonds Community Development.Code (ECDC) and understand that an accessory
dwelling unit, including a second kitchen, as defined in ECDC Section 21.05.015 is
prohibited until an Accessory Dwelling Unit Permit is approved.
I also understand that an Accessory Dwelling Unit Permit cannot be approved unless all
the criteria in Chapter 20.21 are met, and all the necessary items are submitted,
including an affidavit of occupancy and a covenant to be filed with the Snohomish
County regarding the regulations imposed on/A-"essp"- welling Units.
Property Owner Signature:
Property Owner Name (printed):
Date: /I - �Lj -0 -,1--
STATE OF WASHINGTON)
COUNTY OF SNOHOMISH)
I certify that I know or have satisfactory evidence that -Al 1 6 4A f L- b /+ L--) -S c, .-J -
signed this instrument and acknowledge it to be his/her free and voluntary act for the uses and
purposes mentioned in this instrument.,
Notary'- - s4e*,*�-Vl
SC, ION
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Signature of h
Notary Public
/nA-1-4 14/4 , 5 6 J
Residing at: IE U e-Y2��
My Appointment
Expires:
THIS DOCUMENT MUST BE RECORDED WITH THE SNOHOMISH COUNTY AUDITOR.
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CITY CLERK
CITY OF EDMONDS
121 5TH AVENUE NO.
EDMONDS, WA 98020
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STATEMENT ON ACCESSORY DWELLING UNITS
GRANTOR: M1dHhz----L hq&25�0 GRANTEE: &Ltl IV --
Property Address: 9 3706 - 7-4 114,�WE. K165-r
Edmonds, Washington
Legal Description: �AAJC> C-D,508PIV I 5L-t COS- D-01
PK-5-A-= P-7-04-32-Svl
Assessor's Parcel Number:
I have read the requirements for accessory dwelling units contained in Chapter 20.21 of
the Edmonds Community Development Code (ECDC) and understand that an accessory
dwelling unit, including a second kitchen, as defined in ECDC Section 21.05.015 is
prohibited until an Accessory Dwelling Unit Permit is approved.
I also understand that an Accessory Dwelling Unit Permit cannot be approved unless all
the criteria in Chapter 20.21 are met, and all the necessary items are submitted,
including an affidavit of occupancy and a covenant to he filed with the Snohomish
County regarding the regulations imposed oq/A-"essp"- welling Units.
Property Owner Signature: N,�� 1---:=2
Property Owner Name (printed): 141�11z� �-
Date:
STATE OF WASHINGTON)
COUNTY OF SNOHOMISH)
I certify that I know or have satisfactory evidence that M 4A t5" I- b4 Lo -So --J
signed this instrument and acknowledge it to be his/her free and voluntary act for the uses and
purposes mentioned in this instrument..
Notary' sufe I
ScjION
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Signature of
Notary Public:
14-, , 9,F -J
Residing at: jc� U e-YL-C--� 1
My Appointment
Expires:
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THIS DOCUMENT MUST BE RECORDED WITH THE SNOHOMISH COUNTY AUDITOR.
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C. Contractor:
Mailing Address:
State License #:
City of Edmon'S
RIGHT-Or-�W,AY CONSTRUCTION.
PERMIT Permit Number. Cuo 7
Wue Date: 10 (3
A. Address or Vicinity of Construction: 71W
B. Type of Work (be specific): JlLe-_-
Contact:
Phone:
Liability Insurance: . Bond:$
D. Building . Permit # (if applicable): '71-0 '5- 4 1-3 Side Sewer Permit # (if applicable):
E. El Commercial Subdivision 0 City Project E] Utility (PUD, GTE, WNG, CABLE, WATER)
E] Multi -Family Single Family r] Other
INSPECTOR: INSPECTOR:
F. Pavement or Concrete Cut [I Yes ONo G. Size of Cut: x H. Chargq�,$
APPLICANT.TO.READ AND SIGN
INDEMNITY. Applicant understands and by his signature to this application, agrees to hold the City ofEdmonds harmless from injuries, damages, or
claims of any kind or description whatsoever, fpreseen 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 ofany legalproceedings including defense costs, and attorney fees by reason ofgra nting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL
INSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREET PATCH
IS COMPLETED BY CITY FORCES, AT WHICH TIMEA DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THEAPPLICANT..
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.
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 the permit requirements and thepink copyof thepermit willbe
available on site at all times for inspVtion purposes.
Signature- Date:
(Contractor or Agftl
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY ,
APPROVED BY.
T IME AUTHORIZED: VOID AFTER —DAYS
SPECIAL CONDITIONS:
COMMENTS:
DATE:
3
RIGHT OF WAY DEPOSIT —<)
DISRUPTION FEE/FUND III:
RESTORATION FEE:
FEE:
PERMIT
TOTAL FEE:_
z r? 0Ir
RECEIPT.FEE:
ISSUED. BY:,,,
NO WORK SHALL BEGIN PRIOR TO.PERMIT ISSUANCE
Eng. Div. 1994
FIELD INSPECTION NOTES
Comments:
Diagram.:
(Fund I 11 - Route copy to Street Dept.)
CONTRACTOR CALLED FOR INSPECTION El YES
Partial Work Inspection by' P.W.:
Work Disapproved By: Date:
FINAL APPROVAL BY: Date:
El NO
8 9 0 - 1 9) -
City of EdmonnA
JfGHT-OF-WWCON S*' R CTION
PERMIT PermitNumber: !25--- 4�17
Issue Date: x9-- 95
A. Address or Vicinity of Construction: - 23706 74th Avenue W.
B. Type of Work (be specific): GTE to pl ace buri ed servi ce wi re i n Gxi sti nq 211
crosing and plow 151 in R.O.W.. Please see attached drawings.
GTE NorthWest Incorporated
C. Contractor: Mary Bower, Permit Coordinator - Contact: Mary 206/488-1628
Mailing Add 22118 20th Av SE, Suite 130 Phone: ENGINEER: A
ress: 13Gthall, WA 98021 Ni k10 19 r-4 906 ' U71 M 11 or moh:144-4954-0774
State License #: - Liability Insurance: Bond: $
D.. Building Permit # (if applicable): Side Sewer Permit # (if applicable):
E. 0 Commercial Subdivision El City Project M Utility (PUD GTE WNG, CABLE, WATER)
E] Multi-Farnily Single Family E) Other W.O. # 2100-9PCO 242310
INSPECTOR: INSPECTOR:
F. Pavement or Concrete Cutj,. 0 Yes No G. Size of Cut: ix H. Chargq_$
API( - A- T TO READ AND+N,,/
INDEMNITY: Applicant understands and by his signature to this application, agrees to hold the City ofEdmonds 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 or not limited to the defense ofany legal proceedings including defense costs, and attorney fees by reason ofgranting thispermit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FO(R"ZARIbD OF ONE YEAR F1 . OV11WG �FE FINAL
INSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREET PATCH
IS COMPLETED BY CITY FORCES, AT WHICH TIMEA DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THEAPPLICANT.
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.
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 stateme d understand thepermit requirements and thepink copy of thepermit will be
available on site In s urposes.
11
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Signature: (CONTCMRP i J. H. Stewart Date: Jnly 11, 199S
,)Igent) Oprns Supv-OSP Engrg.
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY:, - _1k.1 LA t'-1K
TIME AUTHORIZED.; VOID AFTER ,DAYS.
SPECIAL CONDIfI01NS:
RIGHT OF, WAY DEPOSIT
DISRUPTION FEE/FUND;,111:I'-.
RESTORATION FEE:
PE RMIT FEE:
TOTAL FEE:
COMMENTS: RECEIPT -FE
DATE: ISSUED,,,BY:
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUkNCE
Engrg. Div. 1991