247 4TH AVE S.PDFlill 11111111
5065
247 4TH AVE S
APPLICATION
for
The City of Edmonds SIDE SEWER PERMIT EASEMENT No. . -----------------------------------------
NEW CONSTRUCTION E] REPAIRS E]
101-05600
OWNER........... lrager..,-Kati.l.d.a ...... - ................................................... CONTRACTOR .......... --------------------------------------------------------------------------------------- PERMIT No . ......................
ADDRESS ------- 247 ... 4th ... Ave—.S - -------------- -------------------------------------------- LEGAL DESCRIPTION: LOT No . ..... — ...................................... BLOCK No . ............................................
a -
NAMEOF ADDITION .........................................................................................................................................
DYE TESTED ON SEWER, 1972
Approved:
DATE................................................ By ..................................
#P20 File
Critical Areas Checklist cA N'.
Site Information (soffs/topography/hydrology/ve tation)
1.. Site Address/Location: m2f/
2. Property TaxAccomt Number. 0 Q -pi-0-7 al 2?) t)04170o D
3. Approximate Site Size (acres or square feet)': o o o 4& 1A V7 D -X i -zo Do pa, 94b
4. Is this site currently developed? Yyes; no.
If yes; how is site developed?
5. 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
. . over. a horizontal distance of 33 to 66-feet).
Steep: grades of greater than 30% present onsite (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 Approx Depth:
7. Site contains areas of seasonal standing water: Approx Depth:
What season(sj'of the yor?
.8. Site is in the floodway NO floodplain of a water course.
9. Site contains a creek or an area where water flows across the grounds surface? Flows are year-round?,
Flows are seasonal? (What firne of year?
10. Site is primarily. forested meadow shrubs' p#xed
urban landscaped-oawn, shrubs etc)
11. Obvious wetland is present on site: A10
For City Staff Use Only
1. Plan Check Number, if applicable?
Z Site is Zoned?
3. SCS mapped soil qpe(s)?
4. Critical Areas inventory or CA map indicates Critical Area on site?
5. Site within designated earth- subsidence landslide hazard area? J40
DETERMINATION
STUDYREQUIRED WAIVER
Reviewed br. 4. 'Vv-t—� Date: go --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 persoh'preparing �'Development
Permit Application. for the City of Edmonds prior t6
-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 hrom observations- of the site or data available at
City Hall (Critical areas inventories, maps, or sod
surveys).
Date Received: l,'C-J C/ -'�- -
City Receipt #:_ Z, -_6 1 - 7
Critical Areas File #: /L5_/
Critical Areas Checklist Fee:. $1 ;5.00
Date Mailed to Agmlicant: I /c�.00,9
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.
P lease 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
adchtion, the applicant shall include o1her pertment
information .(e.g. sit; plan, topography map, etc.) or
studies in conjunction with this Checklist to amstant staff
m completing their preliminzy assessment of the site.
The undersign . ed applicant, and hisiber/its heirs, and assigns, in consideration on the processing of the application agrees
to release, indemnify, defend and hold the City of Edmonds harmless brom any and all damages, including reasonable
attorney's fees, &rising fi-om any action or infraction based in whole or part upon false, misleadin& buiccurate or
incomplete information fiirmshed by the applicant, his/herhts.' agents or employees.
By my signature, I certify that the information and exlnbits herewith submitted -am true and correct to the best of MY
knowledge and that I am authorized to file this appli ti " on the behalf of th owner as listed below.
SIGNATURE oiF AppucANTIAGENT. DATE
Property Owner's Authorization
By my signature, I certify that I have authorized the above Applicant(Agent to apply for the s*ect land use application,
and grant my permission for the public officials and the staff of the City of Edmonds to enter the sutlect property for. the
purposes of inspectionand postirF atteVarit to this appli �tion. r- -
. '&'A 4, ;C4 DATE
SIGNATURE OF
I PLEASE PRINT CLEARLY
wnery.�Ppn
CAl-
Name.
. c2 9 0 7 — r2_1P
Street Address
Pd ds q,
-& Pxe-o
city state zip
caMiKepresentauve.-
Name
Strvet Address
1�dpx�_s �,
city State zip
Telephone: V2S— —7-74- Zg—// Telephone:
Email address (optional): Email Address (optional):