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PRINTED IN U.S.A.
CITY OF EDMONDS 0
ASSEAFORMATION SHEET P---
NEW
ADDITION
RETIREMENT
DESCRIPTION
LOCATION
"PURCHASE ORDER NO. -
PURCHASE ORDER DATE
COST
B.A.R.S. ACCOUNT NO.
ESTIMATED LIFE
ASSET NO. oc, 947
ADDITION TO ASSET NO.
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DEPT. NO.
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*PROJECT NUMBER Z's
PROJECT COMPLETION DATE
COST -7
INITIATED BY DATE APPROVE6 BY--�
"SUBMIT ASSET INFORMATION SHEET WITH FINAL PAYMENT REQUEST
*SUBMIT ASSET INFORMATION SHEET UPON CLOSE OF PROJECT
ACCOUNTING ONLY
El DEPRECIATE
MONTHLY DEPRECIATION AMOUNT
ANNUAL DEPRECIATION AMOUNT
0 G.L. ENTRY
REFERENCE
DATE
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V �ARIFIED BY
PROCESSED
BATCH NO.
INITIAL
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DEPARTMENT FILE
CITY OF EDMONDS
A im NEW
FIADDITION
RETIREMENT
DESCRIPTION
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LOCATION DEPT. NO.
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*PURCHASE ORDER NO. *PROJECT NUMBER c4j 1 1
PURCHASE ORDER DATE PROJECT COMPLETION DATE J 6-
COST COST -7/.70
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B.A.R.S. ACCOUNT NO.
AM& ESTIMATED LIFE -�,r
ASSE&FORMATION SHEET
ASSET NO. �t;- :7
ADDITION TO ASSET NO.
INITIATED BY DATE APPROVED BY
"SUBMIT ASSET INFORMATION SHEET WITH FINAL PAYMENT REQUEST
*SUBMIT ASSET INFORMATION SHEET UPON CLOSE OF PROJECT
ACCOUNTING ONLY
DEPRECIATE
MONTHLY DEPRECIATION AMOUNT
ANNUAL DEPRECIATION AMOUNT -
G.L. ENTRY
REFERENCE
DATE
VERIFIED BY
PROCESSED
BATCH NO.
INITIAL
IMP)
GITY OF EDMONDS
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FOR INSPECTION CALL..
PUBLIC WORKS DEPARTMENT Permit 011 � JI,
PUI
775-2525 Ext. 220 Issue Date
DE SEWER PERMIT
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b*-PERMIT MUST BE POSTED ON JOB SITE *A
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2.
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Address 0 S truc Jon
Property Legal Description (include all, easements
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3. Single Family Residence Multi -Family No. of Units
Commercial
4. Owner and/or Builder
5. Contractor & License No.
6. Invasion into City Right -of -Way: No Yes (If Yes Right-of-
way Construction Permit Required Call Dial Dig (342-5344) before
excavation).
7. Cross other private property: Yes No Easement required -
attach legal description and county easement number.
READ THE FOLLOWING AND SIGN:
44
P4
4 a. Property owners must obtain a permit to install side sewers on
>4 their property. A licensed side sewer contractor must be employed to
construct side sewers in the public right-of-way.
b. The side sewer contractor assumes full reponsibility for each
installation for one year.
C. Commercial establishment requires a minimum of a six inch (6")
a4
:E: side sewer line.
0 d. Side sewers may not be installed closer than thirty inches (30")
to any structure.
0
e. Side sewer lines must be laid at a minimum grade. of 2% (1.15
0 and maximum grade of 100% (450). 0
f. No turn in side s8wer greater than 45 (1/8 a] -lord
between cleanout. All 90 turns must be constructed 49-KM
bend) and Wye with removable cap. Dr-cf%n
g. No down spouts, footing drains or floor draFH�X XPqoD
to side sewer system. I nn'Gected
1- 800 - 562-6478
h. Pea gravel is required for bedding when installing sewer lines
through other than granular s.oil.
i. Cleanouts are required at 30"-60" from each plumbing exit line
and at minimum intervals of 1001 along sewer 'line run.
j. Trenches within City right-of-way must be restored to original
conditions. Contractors shall be responsible for right-of-way failure
due to poor compaction of fill.
k. Side sewer must be left uncovered until inspected and approved
by the City.
1. Inspection during normal working hours on1y. Two (2) working
days notice required.
J�7
, 1114
DATE:
certify tha.t'-I have read
and shall comply With the above
-D BY:
PERMIT FEE: DISAPPROVE Date:
By: Date:
CONNECTION FEE:.-,
APPROVED By: Date: :ZT-Fl,
0
PERMIT MUST BE POSTED ON JOB SITE
1!
The City of Edmonds
Side Sewer Drawing
EASEMENT NO . ............................................
NEW CONSTRUCTION El REPAIRS F] LID NO . .................. ASMT. NO . ..................
OWNER CONTRACTOR NO. 61�44.
JOB ADDRESS --------- 3-0.4�7 ...... c—
............... ................... LEGAL DESCRIPTION: LOT NO . ........ ....................... BLOCK NO . ....................................
PWW-0001-11/75 (REV.11/78)
..................................................................................................................................................................
NAME OF ADDITION ------ I—A)YA ..... .4nr 3��:r.K ................................................
JEASeeweni-
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4" pvc- ax:s � "!�J-
Approved:
DATE
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PERMIT SUBMITTED BY
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ROAD BORES
OVERHEAD LINES
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LIG TRENC- T
R.O.W.
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THE FOLLOWING INFO TO 13E PROVIDED
RICHT OF WAY LINES,EOP OR FACE OF CURB, EXISTING SIDEWALK, POLES, ROAD CUTS AND THE UTILITY LINbElli" OAD- CUTS
ABOVE GROUND FACILITIES.(Ie.-) PEDS.BOXES.CABINETS. ETC..UNDERGROUND TRENCHING AND OVERHEAO LINES.
FOOTAGE OF WORK IN R.O.W.
BUILDING DIVISIW Applicant Fill 70NEE�.
Inside Heavy Lines
--PERMIT APPLICATION 7 JOB
NA a JOR NAME OF. BUS ESS) ADDRESS
71 7 ' � 71
NNWER t
i < , f_1 LEGAL DESCRIPTION SUBDIVIS19N SHORT SUB NO.
__'XILING
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PUBLIC RIGHT OF WAY PER OFF STREET MAP
CITY
TftL HONE NUMBER
61
EXISTING A"I
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PROPOSED A4
NAME
DEFICIENCY OF RIGHTK WAY
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PUBLIC IMPROVEMENTS R 1 0
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DRAINAGE IMPROVEMENT RE
DRAINAGE PLAN REQUIRED
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0: CITY
TELEPAONE NUMBER
61 4
Ptf�:P� i4
UNDERGROUND WIRING REQUIRED
CONNECTION TO SANITARY SEWER
NAME
SEPTIC TANK PERMIT REQ'D NO.
ELEVATION OF PROP ERTY CORNERS El
0 ADDRESS
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& FOOTINGS REQ'D
CITY
TELEPHONE NUMBER
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SEE ENGINEERING MEMO WE
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STATE LICENSE NUMBER
CITY LICENSE NUMBER
CHECKED BY
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Legal D I escript I ion of Property NShow Below or Attach Four Copies)
METER SIZE
BUILOI1qG SUPPLY SIZE
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REMARKS
OT
SIGN AREA
ENV. REVIEW
ADD NO.
ALLOWED PROPOSED
COMPLETE EXEMPT
IA a<
-SHORELINE
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REMARKS
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VARIANCE OR CU
PLANNING REVIEW BY
DATE
YARDS LOT
COVERAGE
GAS
FRONT SIDE RIE.Rj
NEW RESIDENTIAL LINE
FIRE ZONE
TYPE OF CONSTRUCTION
HEIGHT
S,r
ADD NON-RESIDENTIAL F_� N
1 ICODE
SPECIAL INSPECTOR
REQUIRED
OCCUPANCY
GROUP
OCCUPAI
LOAD
RETAINING
DEMOLISH WALL
ALTER EXCAVATE FENCE
0 YES NO
I I
EJOR FILL I— X—F*T)
PLAN CHECKED BY THIS SIT E IS LOCATED IN THE CITY
F_j PR I-MIOV E swim
OF EDMONDS. LOCAL SALES TAX
REPAIR
INSP. DPOOL
SHOULD BE CODED 31.04.
REMARKS
z NUMBER OF STORIES
NUMBER 0
0
DWELLING
I
UNITS
NPATURE Jbr WORK TO 13E NE
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PLAN CHECK FEE
VALUATION
FEE
0
PLOT PLAN
BUILDING
PLUMBING
MECHANICAL
FENCE
SIGN
"Applicant, on behalf of his or her spouse, heirs, assigns and
W
.J successors in interest, agrees to indemnify, defend and hold harmless
I the City of Edmonds, Washington, its officials, employees. and
a agents from any and all claims for damages of whatever natu re,
i ( arising directly or indirectly from the issuance of this permit. Islu-
RETAINING WALL
SWIMMING POOL
o ance of this permit shall not be deemed to modify, waive or reduce
�1 inv reniiirement nf inv ritv nrifinanre nor limit in -inv wav the
#0 .00
PUBLIC TAORKS DEPARTMENr CHEacusr
BUILDING PERNIT REVIEW 3 m , r, � � A- ,
(address) tpo
Street Right -of -Way Exist'
REQI�__
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Access Easements Existing 1701?el
REQD
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Utility Easement Exist
W
Lot Per Subdivision Plat
Assessor Map
Site Plan Checked for Accuracy, at
Z
Underground Wiring Reqd. U-40-
1-4
0
Check Accuracy of Legal Descr tion
et
Z
Review by
Date
Existing Water Main Size- D11
Water Main Required
Service Line Required
Hydrant Size Existing
91�
Hydrant Reqd Per Fire Code 4A
Size
Detector Check Meter Reqd. A
1A
Cross Connection Inspection &1A
Fire Department Comments
Wa t er Me t er Charge Req d. -4 S-0, OF
S 22
Review by_ )7��Ot-
_Date
Septic Tank Design Approved A00111,,V
Date
Septic Tank Permit Reqd. &7 `00�
Permit No.
Sanitary Sewer Availability 44c---S:
-PrOj gaw, ',a.. &4 -9 A-.
Dra:wing No.
File No.
Side Sewer Availability
Sanitary Sewer Connection Fee Reqd.
:3:
Review by.
Date
Open Ditch Existing_Z&,e
Reqd.
Culvert Reqd._ Z(42ZZ
Size
C4
Catch Basin Reqd. &&2ae-
Indicate on Site Plan
0
Shoulder drainage M . tain collection
on swale open runoff
ME
I'Zo"le reqd.6r 67
' Indicate on Sli te Plan
Soil Conditions and Gro d Water Field Checked
Review I by
Date
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Revised: lvlO-1977
Page 2
I
oft
11
i.
Street Paving Reqd.
Curb and Gutter Reqd.
Sidewalk Reqd. NA
Curb Cut for Driveway Reqd._ Ajg
Right-of-way Construction Permit Reqd.
Bmd Reqd. for Public Inpravements
Street Name Sign Reqd. Aj
Other Signing Reqd.
P* Pre Permit Site Inspection made an
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f.4 �-4 BY: S&4ER
W WATER
z STREET
ENGINEERING
P4
Special Requirements listed in memo to CoTmunity Development Department,
Building Division
BY Date
All items filled in an Building Permit Application
BY Date
Draw-ing,s Starrped and Notations Made
BY Date
Approved by Public Works Department,
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Revised: Iv 10-1977
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1029 99t h S. E. Bothell, Wa. 98011#44P-0080
CONSTRUCTION INC.
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PLAC F-
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MEMO TO:
FROM
SUBJECT:
DATF:
Building Division
Community Development DepnrtmenL
Engineering Division
Public Works Department
After review of the subject Building Permit application, we have
the following comments:
1. Connection to- City water system required.
2. -Gonnection to City sanitary sewer system required.
3. Right-of-way Permit required for any work on City _property.
4, Driveway slope not to exceed 14011
0
5. Backwater valve required if downsLairs phimbinp is below
elevation of uostream manhole.
6. Water and sewer lines to be separaced by 1.0 foot minimum.
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na u iu7r—(e
.�AILDING DIVIS1W
TER MIT APPLICATION
NA It JOR NAME OF. BUS ESS)
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N A M E
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�STA E LICENSE
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Leaal Descricition
USE
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Applicant Fill ZONE
Inside Heavy Lines 0 Ps
JOB
-fA D D:R E SS N-1
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EGAL DESCI
PER'MiT
NUM13ER
.S- T__ I, Y_ f � C141 I! 1Q_1
ION I SUBDIVISION I SHORT SUB Nu.
s7F.
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PUBLIC RIGHT OF WAY PER OFF[ �AVSTREET MAP
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JTE�LEPHONE NUMBER
EXISTING 04?+e' e?,& r
PROPOSED F 14
&CE -
DEFICIENCY OF RIGHT OF WAY
PUBLIC IMPROVEMENTS
ZZ I - 6 Z98
Rq;rED
DRAINAGE IMPROVEMEN Ulf C3
DRAINAGE PLAN REQUIRED
-rELEP14ONE NUMBER
UNDERGROUND WIRING REQUIRED
CONNECTION TO SANITARY SEWER
SEPTIC TANK PERMIT REQ'D 0 NO
ELEVATION OF PROPERTY CORNERS
& FOOTINGS REQ'O
TELEPHONE NUMBER
SEE ENGINEERING MEMO WED
IdUMBER
CITY LICENSE NUMBE—R
CHECKED BY
if Property '(Show Below or Attach Four Copies)
METER SIZE
BUILDI(4G SUPPLY SIZE
REMARKS
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40T �_.75 �44xl Amj
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0
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SIGN AREAPOSED �COMENV. REVIEW
ALLOWED I PRO PLETI EXEMPT
REMARKS
VARIANCE OR CU
YARDS
GAS
New RESIDENTIAL E] LINE
ADD NON-RESIDENTIAL SIGN
DEMOLISH RETAINING
WALL
ALTER EXCAVATE FENCE
OR FILL I— X—FT)
FRONT
FIRE ZONE
TY
I
SPECIAL INSPECTOR
REQUIRED
0 YES El NO
PLAN CHECKED BY
REPAIR PRE -MOVE swim
INSP. POOL
REMARKS
z NUMBER OF STORIES
NUMBER OF
DWELLING
UNITS
WA TURE bF WORK TO 13E PjbNE
it
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0
PLAN CHECK FEE
PLOT PLAN
rBUILDING
PLUMBING
MECHANICAL
FENCE
SIGN
In "Applicant, on behalf of his or her spouse, heirs, assigns and
0
RETAINING WALL
III
.J successors in interest, agrees to indemnify, defend and hold harmless
2 the City of Edmonds, Washington, its officials, employees. and
agents from any and all claims for damages of whatever natu re,
x arising directly or indirectly from the issuance of this permit. Isu-
SWIMMING POOL
PLANNING REVIEW BY DATE
LOT COVERAGE
SIDE REAR I
F CONSTRUCTION ICODE HEIGHT
AREA OcCUP7kNcy OCCUPANT
IGROUP LOAD
THIS SITE IS LOCATED IN THE CITY
OF EDMONDS. LOCAL SALES TAX
SHOULD BE CODED 31.04.
VALUATION I FEE
al ance of this permit shall not be deemed to modify, waive or reduce
.J
0 any requirement of any city ordinance nor limit in any way the
WORKS DEPARTIEPCHECKLIST
BUIIDING PE109T REVIEW
"L�address) (date)
0
Street Right -of -Way Exist' I-L
REQD
Z
I
Access Easements Existin We/V1
REQD
1-4
Utility Easenient Exist
Lot Per Subdivision Plat Assessor Map_Cr
Site Plm Checked for Accuracy,
Z
Underground Wiring Reqd.
1-4
0
Check Accuracy of Legal Description '(9e
Z
Review by_
Date
Existing Water Main Size, 9
Water Main Required
Service Line Required
Hydrant Size Existing.
iX
Hydrant Reqd Per Fire Code �XLA
Size
Detector Check Yeter Reqd. N A
Cross Connection Inspection
A
E-
Fire Departumt Conuients
F
.4ater Meter Charge Reqd.
a- 7
Review by Fgj—e--- Z
Date
Septic Tank Design Approved
Date
Septic Tank Permit Reqd.
Permit No.
Sanitary Sewer Availability
Pr 03-
Drawing No. - =_
File No.
Side Sewer Availability
Sanitary Sewer Connection Fee Reqd.
:3:
Review by
Date
W
-
Open Ditch Existing. &2.�Z
Reqd.
Culvert Reqd._ _
Size
04
Catch Basin Reqd.
Indicate on Site Plan
0
Shoulder dra' ge tain collection on
swale open runoff
�bnh7ole reqd. C.
Indicate an Site Plan
Soil Conditions and Ground Water Field Checked
L
Review by,
Date
13-
Revised: lvlO-1977
Vit nf Fdmnnde Permit No: 2C00
.7
RIGHT-OF-WAY CONSTRUCTION PERMIT Issue D
ate: e�2�2COO
A. Address or Vicinity of Construction: 305 fir P1
B. Type of Work (be specific):GTE to place, operate i and maintain a bu,ridd service w6re f rom
existing PEDESTAL # 0931 located at 1100 4th'Aye S. then SOUTH to a ragldAnna at
305 FIr P1. GTR to pinw 900 fept,v�iqh I driuPwavn, 60 feet , and push 0 roads.
Pavement or Concrete cut needed -yes size of cut 2-2'x5' . R.O.W. footage is 260 feet.
C. Contractor: GTE NOWTHWEqT TNr
Mailing Address: 2312-C W. Casino Rd
Everett Wa 98204
State License #:
D. Building Permit # (if
E. Commercial
Multi -Family
Terry Anderson 425-771-8683
Contact: Sherry Jones -Permit Coordinator
Phone: 425-710-4133
Liability Insurance: Bond:$
Side Sewer Permit # (if applicable):
Subdivision F] City Project a EUC (PUD,(2JTE PSE, CHAMBERS, OVWD)
Single Family F� Other
GTE W.O. #2100-9POOlDB 2423.10
fNSPECTOR-
F. PAVEMENT: [:]YES G.- SIZE 6F CUT 2' x 5' H. Charge:
CONCRETE CUT: M YES NO
APPLICANT TO READ AND SIGN
IDEMNITY. Applicant understands by hislhe r signature to this applica ' tion helshe holds the City of Edmonds harmlessfrom 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 CONTRACiOR IS RESPONSIBLE FOR wbRkmANsHiP—AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL
INSPECTION AND A CCEPTANCE OF THE WORK ESTIMA TED RESTORA TION FEES WILL BE HELD UNTIL THE FINAL STREET PA TCH IS
COMPLETED BY CITY FORCES, A T WHICH TIME A DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT.
1
* 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) 2967155-305 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.
IRAVEREAD THE ABOVE STATEMENTS AND UNDERSTAND THE PERMIT REQUIREMENTS AND ACKNOWLEDGE
THA T I MUST MAKE THE PINK COPY OF TIIE A VAILABLE ON SITE A T ALL TIMES FOR INSPECTIONS
Signature: Date3-14 - (�OX
(Contractor or Agent)
CALL DIAL -A -DIG (1-800-424-5555) PRIOR TO BEGINNING WORK
FOR CITI
.�pproved,,,by
% Thime A,uth1)rize.1--'Void'4,ft r (d 1- 60
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I:;;,. rie%<& .,v, &r
�AAWIVTI
rot avimn ,n
SE. ONLY
Right-of-way Fee: -10'-' 4 5
Disruption Fee/Fund 111:
Restoration Fee:
Total,Fee:
Receipt No:
Issued by: '1''_1 41
UPON COMPLETION OF PERMITTED WORK, AN ENGINEERING FINAL
INSPECTION IS REQUIRED PER CHAPTER 18.00 OF THE EDMONDS
COMMUNITY DEVELOPMENT CODE.
-FINAL APPROVAL OF PERMITTED WORK. 641F
INSPECTOR'S SIGNATURE DATE:
I 1� I . I . � -6% 06
For inspection requirements see Engineering Information Handout. lil.VA41
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