319 ADMIRAL WAY.PDF13775
319 ADMIRAL WAY
ADDRESS:
TAX ACCOUNT/PARCEL NUMBER:
BUILDING PERMIT (NEW STRUCTURE):
COVENANTS (RECORDED) FOR:
CRITICAL AREAS:
DISCRETIONARY PERMIT #'S:
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
PERMITS (OTHER):
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED:
DETERMINATION: E] Conditional Waiver E] Study Required Ej Waiver
SEWER LID FEE $: LID #:
SHORT PLAT FILE: LOT: BLOCK:
SIDE SEWER AS BUILT DATED:
SIDE SEWER PERMIT(S) #:
GEOTECH REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
WATER METER TAP CARD DATED:
OTHER: �DW
LATEMP0S'rs\Forms\Street File Checklist.doc
STREET USE PERMIT APPLICATION
NAME OF APPLICANT
NAME OF BUSINESS: 1!m QnZEW-X�
MAILING ADDRESS: t"-� L)
CONTACT PERSON AND PHONE
ADDRESS OF PUBLIC USE:
Describe the public place or portion of public space to be utilized:
7K) ot:S
the type of use desired
Specify the length of time for use: k4�ZQ�,h 2.�L Yr,
NOTE: 7he issuance of this permit is understood by the applicant to be of a temporary nature and that no vested right is
granted
INDEWN17Y. Theapplicant niLdfitiaYnd, and by hiAer signature to this application, agrees to hold the City of Edmonds
u ' r
ltym? Is
harmlessf juries, d in I' , k f
rom any in a agesl cl�a any kind or description wha oever, foreseen or un oreseen, that may
o7r,. -_ I
be made against the applicant or the City �'fg4inqWs; or any of its departments or employees, including but not limited
to the defense or any legal proceedings inclu 'n'- de ense, /, Is, court costs, and attomeyfees by reason ofgranting this
permit. In addition, the application understands tha Ae"Cl i be provided a Certificate of Insurance to indemnity
and hold harmless the City of Edmondsfrom all claims an 6r-fp;�per� damage, and naming the City of Edmonds as an
additional insured.
I
CODE APPLIC4 TION.- By signing the application below the applicant warrants that s1he has read or had the
opportunity to read Chapter 18 of the Edmonds Community Development Code and s1he understands that all terms of the
adopted ordinance are incorporated herein as ifsetforth in full and this application and permits therefore are subject to
the terms of that Chapter.
I/
STRUSEHO.DOCJLG/2-95
SIGNATURE OF APPROVAL FROM ABUTTING PROPERTY OWNERS
When applicable, if the street use proposal directly impacts any adjacent business or private property
owner the applicant must obtain written approval from the affected parties. This requirement is
evaluated by City Staff after the initial submittal of the application.
Signature Address
Signature Address
Signature,
Address
Signature Address
DO NOT WRITE BELOW TFUS, LINE --FOR CITY USE ONLY
Planning Division Review:
ADB# 111114
Approved By I Pate
Public Works Review: ,; Approved By
C 7Zvd -� 2 1 - 'k) $A- V"
Fire Departmer)t Review: Approved By
Polip D yartent Review: Approved By
/ tj CC
Date eo(—.;)3
Date
Dat
Permit Coordinator kevieW'- "C6rfificate of Insurance Verified 4-,?,S - n, 2
Enrin Division Review,: Bond Required — Amount $
/ M�
ApprovedB Dated JL2� J(
Remarks or Comments:—
PERNUT # DATE OF ISSUANCE_ IRZ -960
RELEASED BY S. —RECEIPT 9 A5-0
STRUSEHODOOLG/2-95
-Fir'fl- 11'j- � 'jb r- �' i I:D : I LJ I D : HN(-HUX' I N'nUHHNU=
POLICY NUMBER.- EPA 0*879
1 �-L NU: tVJ-- #659 POZ
OCOMMERCIAL GENERAL LIA131LITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:,
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE RE: EDMONDS BOAT YARD
Name of Person or Organization:
THE CITY OF EDMONDS, ITS
OFFICERS AND EMPLOYEES
(if no entry appears above, Information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
WHO IS AN INSURED (Section 11) is amended to include as an insured the person or organization shown in the
$chedule. but only with respect to liability arlsing out of "your work" for that insured by or for you.
I
CG 20 10 1185
Copyright, Insurance Services Office. Inc.. 1984
A
CUSTOMER # 10134 C E R T I F I C A T E 0 F I N S U R A N C E ISSUE DATE: 04/19/96
= ==== == = = M=2= mmazzmazz Mu==== 2MMMMnam =a Q=M= == =M:;: ==%_== = == = =M==MwMMM =Qm== n ===w :
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
ANCHOR INS. & SURETY INC NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFtCATE DOES NOT AMEND,
6 500 CENTURY TOWER EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
201 SW 12TH AVE,
ORTLAND, OREGON COMPANIES AFFOROINU COVERASE
ZIP CODE ?7205-2030 COMPANY LETTER A VALIANT INSURANCE CO
---------------------------------------- I
COMPANY LETTER 8 NORTHERN INSURANCE
INSURED
WALSH CONSTRUCTION CO.
ATTN: BURKE RICE
3015 SW FIRST AVENUE
PORTLANO.OREGON
ZIP CODE 97201
COMPANY LETTER C
COMPANY LETTER 0
COMPANY LETTER E
==== 22 z===MM=== C= am a a Zz tLl ft:tm =tc=M=M=M Mau== am 09 m a =Z# a cwmmm am mamw ma V:q
COVERAGES
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO
WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT
TO ALL THE TERMS, EXCLUSIONS, AND CONDITIONS OF SUC4 POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
im =Z== = =c= a 9m9M=v.M =Mu --------- = ...... a am awmanummmm =am W, gamm= ===e 2 === ====L-elM&=vvtrw Pop*.
CO POLICY POLICY
LTR TYPE OF INSURANCE POLICY NUMBER EFF. DATE EXP, OATE LIMITS
M;2= =am== a �zam a awma=m a 22 2 L.=!! 1'!!e=wM'M2 nu.1323
GENERAL LIABILITY GENERAL AGGREGATE - t 21000,000
A (X) COMMERCIAL GENERAL LIABILITY EPA 08835879 03/01/96 03/01/97 PRODUCTS-COMP/OP 400. s 1,000,000
C ) CLAIMS MADE (X) OCCUR, PERSONAL & ADV, INJURY 6 1,000,000
(X) OWNER'S & CONTRACTOR'SPROT, EACH OCCURRENCE * 11000,000
FIRE DAMAGE (ANY ONE FIRE) S 50,000
MED, EXPENSE (ANY ONE PERS) 1 5,600
---- - ------------------------------------------------------------------------------------ -------------------------------
AUTON081LE LIABILITY
A M ANY AUTO ECA 12556115 03/01/96 03/01/97 COMBINED SINGLE LIMIT t 1,000,000
ALL OWNED AUTOS
SCHEDULED AUTOS BODILY INJURY (PER PERSON) S
HIRED AUTOS
NON�OWNED AUTOS BODILY INJURY (PER ACC) $
GARAGE LIABILITY
PROPERTY DAMAGE s
-------------------- 7 ---------------------- --------------------------------------------------------------------------------
,jEXCESS LIABILITY
(X) UMBRELLA FORM FORK UBA 68128397 03/01/96 03/01/97 EACH OCCURRENCE
( ) OTHER THAN UMBRELLA I AGGREGATE t 51000,000
-------------------------- ------------------------------------- ------------------------------------------
( ) STATUTORY LIMITS
WORKER'S COMPENSATION EACH ACCIDENT $
AND DISEASE -POLICY LIMIT $
EMPLOYER'S LIABILITY DISEASE -EACH EMPLOYEE s
------------------------- ------------------------------- ----------------- - ------ I ---------------------------
IOTHER I I
---------------------------------------------- I --------------------------------- I ---------------------------
DESCRIPTION OF OPERATIONS/LOCATrONS/VEHICLES/SPECIAL ITEMS
- REt EDMONDS BOAT YARD -
CERTIFICATE HOLDER CANCELLATION
CITY OF EDMONDS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
BUILDING DIVISION EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
250 STH AVENUE NORTH 30 DAYS URITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
EDMONDS, WASHINGTON BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
ZIP CODE 98020 OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
------------------------------------------------------------------------------------------------------------------ I-, --------
AUTHORIZED REPRESENTATI
JAMES P, OOONEY
07�
LIN
Cit y of, onc*
RIGHT-OF-WAY CONSTRUCTION,�
Al:
,J
PERMlY 7.e/
--domm— C�
90 - 19
Permit Numbem
Lssue Date: (I
-7
A. Address or Vicinity of Construction: Dayton St & Admiral Wy 6
B. Type of Work( be specific):
Set valve box for test wires
14% C/L W Dayton S & 210',E C/L Admiral W
t y
C. Contractor: - Washington Natural Gas Contact: Anita Yurovchak
MailingAddress: 1122 75 St SW Everett Phone: 356-7500 X9304
State License #: �98203 Liability Insurance: Bo . nd:$
D. Building Permit # (if applicable): Side Sewer Permit # (if applicable):
E. Commercial Subdivision 0 City Project K) Utility (PUD, GTE, WNG, CABLE, WATER)
Multi�Family 0 Single Family 0 Other
�.J
INSPECTOR: INSPECTOR:
'�12
F. Pavement or Concrete Cut: Yes ONo G. Size of Cut: L_Zx H. Chargq,$
APPLICANT TO READ AN GN
INDEMNITY. Applicant understands and by hie signature to this application, agrees to OfEdmonds harrnlefs fr dam
/,nies, ages, or
clainw of any kind or description whatsoe�er, foreseen or unforeseen, that may be t the City of Edmon4l�or cry of Sth departments or
employees, including or not limited to the defense of any legalproceeding8 &tclud e costs, and attorney fees 4r"easo. ofgrahting thi.perft.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATE*- PERIOD OF ONM FOLLOWING 771E FINAL
Tr
t
INSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES WILL BE HELD UNT T kPAYJL STREET PATCH
IS COMPLETED BY CITYFORCES, AT WHICH TIMEA DEBIT OR CREDIT WILL BEPROCESSED FOR ISSUANCE TO TH&APPLICANT.
Construction dTavying of proposed work required with permit application.
A 24 hour notice is4equired for inspection; P16 ase 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 CAy Engineer.
All street cut ditc ' hes shall be patched with asphalt or City approved material prior to the end of the working day;
NO EXCEPTIONS.
Ihav'e read the above statements and understand thepermit requirements and thepink copy of thepermit will be
available on s y'e at all 16es for inspection purposes.
Date:
Signature: /� � 7/;-/Z/ —/// /I I /,;,/ 10-23-06
(f9ontractc(ror Aiei�W'
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY-,,6i-6�4
. k6VEW ��-'R1GHT-,OF.Wj'iK'b0iO'C
FUND��Lll
.'ON -FEE -A
Z
M
i"SPECL&L�CONn '3'��k.�!IRESTORAn[0?4,'F'-EE-'--�"
-"F:
i�RMITFE �`O
kA
CODME W.
V. -;—q
X.
-p�,�,,TSUED BY-,-
z�u
NO WORK SHALL BEGIN PRIOR TO EIRMIT hSUA-NCE
Eng. Div. 1994
City of. Edmondlo
RIGHT-OF-WAY CONSTRUCTION
PERMIT 7
er.
Permit,Numb
LssueDate: 412_2_1f)l
A. Address or Vicinity of Construction: .3/9 AD"izA(_. Wa
B. Type of Work (be specific): �DFM
9 0
C. Contractor: Qrll)-w 0 0�7k 013. Contact: -_Je_T7J- fjg&�At
Mailing'Address: t/ng7 M. Phone: Aua- 547- 1400h
StateLicense#: Liability Insurance: Bond: $
AL
D. Building Permit# (iCapplicable): ZT_ Side Sewer Permit # (if applicable): AJ
h E*-f o 6 tL L3 4+TVACD 12 &1044rt�
E. F] Commercial - E) Subdivision El City Project E] Utility (PUD, GTE, WNG, CABLE, WATER).
Multi -Family El Single Family EJ Other
INSPECTOR: INSPECTOR:
F. Pavement or. Concrete Cut Yes []No G. Size of Cut: x H. Chargq�,$
APPLICANT TO READ AND SI,GN-
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 legalproceedings including defense costs, and attorney fees by reason ofgranting thispermit.
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 TIME A DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THEAPPLICANT.
Construction draWirig 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 abovestatements and understand thepermit requirements and thepink copyof thepermit willbe
available on site at all times for inspection purposes.
Signature.- Date: a.
���Ilc6dtra&rlo'r Agent)
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY: RIGHT OF WAY DEPOSIT
TIME AUTHORIZED: VOID AFTER DAYS DISRUPTION FEE/FUND .111:
SPECIAL CONDITIONS: RESTORATION FEE:
PERMIT FEE:'*
COMMEN TS:
_DATE,-,:*4Az_3 E%�
TOTAL,FEE:
RECEIPT FEE: alz 9/
ISSUED BY:
C
NO WORK SHALL BEGIN PRIOR TO, PERMIT ISSUANCE,
Eng. Div. 1994
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