541 HEMLOCK ST.PDFIIIIIIIIIIIIII
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541 HEMLOCK ST/X6�y
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CITY OF EDMONDS
CIVIC CENTE0 - EDMONDS. WASHINGTON 98020 - (206) 775-2525
f-] PURCHASE REQUEST RINVENTORY REQUEST
CONFIRMATION
ORDER
1:1 WORK REQUEST
THIS NUM13ER MUST APPEA0
ON ALL INVOICES,
PACKAGES, BILLS OF LADING
AND CORRESPONDENCE.
VENDOR PHONE NO.
VENDO.Ft NO.
DOCUMENT NO.
ORDER PATE
BATCH DA
20448
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REQUESTED BY -
APPROVED BY:
RECEIVED BY:
1�1
PLEASE FURNISH THE FOLLOWING ITEMS:
CODE- PROJECT AMOUNT
ESTIMATE ACTUAL
7-!5-, o-e:5,
2
3,
4
5
6,
7
8
9
101
0 1
12
TOTA L AMOUNT
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CITY OF EDMONDS
PUBLIC WORKS DEPARTMENT
RIGHT - OF - WAY CONSTRUCTION PERMIT
A. *Address vicin i!y of Construction
,r7>� � - 5LI-3 �-KFMLOC IC
9 Owner:
Name
7-
, �' 10 (' I
Mailing Address
ZVMONDS Wn 9&LO
City, S ta te, Zip Code
9 Contractor: j::� � J
Nam
�-�Ipla Qe., C19
M III Address
`uq 9 WA
City! State, Zip Code
Permit No.
Issue Date
9 Permit Issued To:
on 'r
• TypeofWorktobeD q-:
,T_pe
_ _ i'.'JCV4 FZA N 14, 1 W ST A
• Work in Connection GAJECT91C L-k�JL
0 Sub or Plat Single Family
El Comml. / Ind. 0 Apt. Condo.
0 Pavement Cut: D Yes No
0%
State Lice-ase vrpbe
I �—i — �'i i
P 64.
Telephone Number
* * NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE * *
B. APPLICANT TO READ AND SIGN
INDEMNITY: Applicant understands and by his signature to this application, agrees to hold the City of Edmonds harmless
from any 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 of any legal
proceedings including defense costs, court costs, and attorney fees by reason of granting this permit.
Upon issuance of this permit, the contractor is responsible for workmanship and materials for a period of one year
following the final inspection and acceptance of the restoration by the Engineering Division.
Funds held from the Security Deposit (estimated restoration fee) will be held until the final street patch is completed, at
which time a . debit of credit will be processed for issuance to the applicant.
Work is to be inspected. Restoration to be in accordance with City Code. Traffic Control to be in accordance with Traffic
Section of City Code. Street to be kept clean at all times. A 24 - hour notice is required for inspection by Engineering.
Call 775-2525, extension 220.
I understand that this permit'must be available at the job iite for I p pon purposes at all times.
Signature: �\ J*L4&& \\ Date 7- - PIZ
Owner or Agent
THIS PERMIT MUST BE POSTED AT THE JOB SITE FOR INSPECTION' PURPOSES
CALL DIAL - DIG PRIOR TO BEGINNING WORK
C. Issued Bv: M To —
Time Authorized: Vold after e5�— days
Special Conditions:
Ammendments:
Permit Fee:
Security Deposit:
Receipt No.: .
Fund III Fee:
Street Cut Dimensions
X
* * NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE * *
Eng. Div. December 1978
FIELD INSPECTION NOTES T
(Fund 111 - Route conv to Street nent]
Comments:
Diagram:
Contractor called for inspection yes No
T
.A7ork DisaT)proved By: Date: Bv: Date:
Work Approved By:-- —Date:
Inspector:
Ena. Div. December 1978
PUBLIC UTILITY DISTRICT: No I of Siu*omtsh C unty
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'CITY OF EDMONDS
FOR INSPECTION CALL
PUBLIC WORKS DEPARTMENT Permit 1 0
775-2525 Ext.� =_
SIDE SEWER PERMIT Issue Date
PEP -MIT MUST BE POSTED ON JOB SITE
'77®r
1, Address 0 nstruction
2. Property Legal Description (include all, easements) FnMnWC)S
=TREATM&47. PLANT
1112A -Ij/ 7— PLAN:
3. Single Family Residence Multi -Family No. of MO
Commercial j AN 1983
4. Owner and/or Builder
PUBLIC WORKS
5. Contractor & License No.
6. Invasion into City Right -of -Way: No__,,,,,"e' s (If Yes Right-of-
CiKe
way Construction Permit Required - Ca 1 -5344) before
excavation). �g (342
E-4 7. Cross other private property: Yes No_,,/ Eas t�equired -
U attach legal description and county easement number.
READ THE FOLLOWT.NG AND SIGN:
P4
44
9C a. Property owners must obtain a permit to install side sewers on
>-I their property. A licensed side sewer contractor must be employed to
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construct side sewers in the public' right-of-way.
b. The side sewer contractor assumes full reponsibility for each
E-4 installation for one year.
W
4 C. Commercial establishment requires a minimum of a six inch (6")
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side sewer line.
d. Side sewers may not be installed closer than thirty inches (30")
L) to any structure.
4 0
e. Side sewer lines must be laid at a minimum grade, of 2% (1.15
and maximum grade of 100% (450). 0
f. No turn in side sswer greater than 45 (1/8abend) is 0 allowed
between cleanout. All 90 turns must be constructed of a 45 (1/8
bend) and wye with removable cap.
g. No down spouts, footing drains or floor drains can be connected
to side sewer system.
h. Pea gravel is required for bedding when installing sewer . lines
through other than granular soil.
i. Cleanouts are required at 30"-60" from each plumbing exit line
and at minimum intervals of 100' 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 only. Two (2) working
days notice required.
DATE: O."o, � A
I cer,tif hat I have read
and s;halyi/Ttomply wAh the above
PERMIT FEE: ;3(). DISAPPROVED BY: Date:
00 By: Date:
CONNECTION FEE'.
94:=) APPROVED By����Date:,Q
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44 * PERMIT MUST BE POSTED ON JOB SITE
The City of Edmonds Side Sewer Drawing
EASEMENTNO . ............................................
NEW CONSTRUCTION 2r REPAIRS LID NO . ................... . ASMT. NO . ..................
OWNER . . ...... .............................. CONTRACTOR 4 ?�' a.,
........ PERMIT NO. .
JOB ADDRESS -07�'./ .....
........ ------ ...... LEGAL DESCRIPTION: LOT NO . ............ 7 ...................... 13LOCK NO . ....................................
............. ........................... I ....... ... .. .........
IDMONDS .......
P��T
NAME OF ADDITION ..... NT PLANT
..
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PWW-OW I - 11/75 (R EV. 11/78)
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Approved:
DATE .... .........
................
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CITY OF EDMONDS
ASSET INFORMATION SHEET
NEW
ADDITION
RETIREMENT
ASSET NO.
ADDITION TO ASSET NO.
DESCRIPTION SERIAL NO.
LOCATION DEPT. NO.
"PURCHASE ORDER NO. -
PURCHASE ORDER DATE
COST
B.A.R.S. ACCOUNT NO. 40 1
ESTIMATED LIFE z Z
*PROJECT NUMBER
PROJECT COMPLETION DATE
COST 2- 2 87-
INITIATED BY DATE APPROVED BY
"SUBMIT ASSET INFORMATION SHEET WITH FINAL PAYMENT REQUEST
*SUBMIT ASSET INFORMATION SHEET UPON CLOSE OF PROJECT
ACCOUNTING ONLY
EKDEPRECIATE
MONTHLY DEPRECIATION AMOUNT
ANNUAL DEPRECIATION AMOUNT -
0 G.L. ENTRY
REFERENCE
DATE
VERIFIED BY
PROCESSED
BATCH NO.
INITIAL
(tnp
DEPARTMENT FILE
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CONSTRUCTION PERMIT APPLICATION
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NAME (08 NAME OF BUSINE�S)
LEGAL DESCRIPTION 11EC11
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LID NO.
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17A_11 ING ADDRESS
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP.
CITY
TELEPHONE NUMBER
EXISTING-_50— REQUIRED DEDICATION
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TELEPHONE NUMBER
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NAME
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METER SIZE
BUILDING SUPPLY SIZE FIXMRE
UNITS
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TELEPHONE NUMBER
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REMARKS
STATE LICENSE NUMBER
CITY LICENSE NUMBER
SIGN AREA
ALLOWED PROPOSED
ENV. REVIEW
COMPLETE I EXEMPT
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Legal Description of Property - include all easements
(show below or attach four copies)
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LOT COVERAGE
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REMARKS
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2�NEVV RESIDENTIAL PLUMBING
ADDIALTER NON-RESIDENTIAL MECHANICAL
REPAIR RETAINING WALL SIGN
EXCAVATE FENCE
CHECKED BY
TYPE OF CONSTRUCTION CODE
HEIGHT
DEMOLISH OR FILL (_ x FT)
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PRE -MOVE INSP.1 swim
COMPLIANCE INSP. PQQIL
SPECIAL INSPECTOR "fA.REA
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CCUPANCY
GROUP
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OCCUPANT
LOAD
SIDE SEWER WATER LINE
REMARKS
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NUMBER OF STORIES
NUMBEROF
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NATURE OF WORK TO BE DONE (ATTACH PLOT PLAN)
VALUATION
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PLAN CHECK FEE
BUILDING
PLUMBING
MECHANICAL
This Permit covers work to be done on private property ONLY.
GRADINGIFILL
Any construction on the public domain (curbs, sidewalks,
driveways, marquees, etc.) will require separate permission.
Permit Application: 180 Days
Permit Limit: 1 Year - Provided Work is Started Within 180 Days
"Applicant, on behalf of his or her spouse, heirs, assigns and
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successors in interest, agrees to indemnify, defend and hold
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armies the City of Edmonds, Washington, its officials,
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employees, and agents from any and all claims for damages of
a:
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whatever nature, arising directly or indirectly from the issuance
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DATE: A9-
MEMO TO: Building Division
Planning Department
FROM: Engineering Division
Public Works Department
SUBJECT: -5-1
After review of the subject Building Permit application, we have the following
comments:
1. Connection to City water system required.
2. Connection to City sanitary sewer system required.
3. Right-of-way permit required for any work on City property.
4. Driveway slope not to exceed 14%
5. Backwater valve requ ired if downstairs plumbing is below elevation of
upstream man-Fo-T—e.
6. Water and sewer linesto be separated by 10 foot minimum.
BD 6/82
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PUBLIC wows rmmo;r mEacun
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(ackiress) (date)
Street Right -of -Way Existin�.�...
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H I Access Easements Existin&____=±___.MqL_
g Utility Easement Existing____=_____.REQr�__
W lot Per Subdivision Plat Assessor MP-2
W Site Plan Checked for Accura,
Z
H Underground Wiring Reqd._ Ile
u ICheck Accuracy of Legal Descri�tion
Z Review by Date
Existing Water Main Size
Water Main Required
Service Line Required
Hydrant Size Existi
9 Hydrant Reqd Per Fire Code - Size
94 Detector Check Meter Reqd.
1-4 Cross Connection Inspection
< Fire Department Comnents
lWater Meter Charge Reqd._:�_j
Review by Date
Septic Tank Design Approved " ?
&//A Pate Ile,
Septic Tank Permit Reqd. Permit No.
Sanitary Seuver Availability Proj
Drawing No. — /_ / �) 7Lf File No.
Side Sewer Availability
W Sanitary Sewer Connection Fee Reqd.
Review by__ Date //.P
OPen Ditch Existing___Z��...�Reqd.
:C Culvert Reqd. Size
W Catch Basin Reqd. Indicate on Site Plan
0 Shoulder drainage maintain collection on swale open runoff
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0 Mat-liole reqd.
Indicate on Site Plan
Soil Conditions/and Ground Water Field Checked
Raview by
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121 5TH AVENUE NORTH - EDMONDS,WA 98020
PHONE: (425) 771-0220 - FAX: (425) 771-0221
*PERMYIP MUST BE POSTED ON JOBSITE*
STATUS: ISSUED ENG20060471
I RIGHT OF WAY PERMIT (6-EUC Blanket)
Permit Number: ENG20060471 Expiration Date: 12/18/2006
Job Address: 541 HEMLOCK ST, EDMONDS Location:
CONTRACTOR
PUGET SOUND ENERGY
P.O. BOX 90868
BELLEVUE. WA 98009
LICENSE #: EXP:
JOB DESCRIPTION
Install gas service.
DISRUPTION INFORTMATION
ASSESSED VALUE: $0.00 PROPERTYAREA: 0
SIDEWALK: (OXO) DURATION IN MONTHS: 0 FEE: $0.00 STREET DISRUPTION TRENCH CUT: 0 x 0
PARKING: OXO ) DURATION IN MONTHS: 0 FEE: $0.00 YEAROFOVERLAY: 0 FEE: $0.00
ALLEY: OX0 ) DURATION IN MONTHS: 0 FEE: $0.00
INDEMNITY- The Applicant has signed an application which states helshe holds the City ofEdmonds harmlessfrom injuries,
damages or claims ofany kind or description whalsoever, foreseen or unforeseen, that may he made against the City ofEdmonds or
any ofits departments or employees, including but not limited to the defense ofany legal proceedings including defense costs and
allorneyfees hy reason ofgranting this permit.
TUECONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FORA PERIOD OFONEYEAR FOLLOWING THEFINAL
INSPECTIONAND ACCEPTANCE OF THE WORK
• 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) 296-155-305 and must have certification verifying completion of the required training in their
possesion.
• 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.
CALL DIALA-DIG (1-800424-5555) BEFOREANY EXCAVATION
CALL FOR INSPECTION (425) 771-0220 EXT. 1326
24 HOUR NOTICEREQUIRED FORALL INSPECTION REQUESTS
APPLICATION APPROVAL
THIS APPLICATION IS NOT A PERMIT UNTIL SIGNED BY ME CITY ENGINEER OR HISMER DEPUTY: AND FEES ARE PAID, AND RECEIPT IS ACKNOWLEDGED IN
SPACE PROVIDED.
Printed: Wednesday, October 18, 2006
RELEASED BY
DATE
F-1 FILE COPY INSPECTORCOPY F-1 APPLICANT COPY
STATUS: ISSUED
ENG20060471
• Restore ROW to City standards
• Restore Landscape to like or better conditions.
• Call for locates of underground utilities prior to any excavation.
• Public utilities maintain 5'separation from City Utilities.
• Verify clear bore crossings
• Utility patch restoration to be in accordance with Edmonds Standard detail E2.3
• Maintain erosion & sedimentation control. Keep street clean.
• Construction hours are Monday -Friday 7am-6pm and Saturdays 10am-6prrL No work on Sundays or Federal Holidays.
• Traffic Control per approved plan and MUTCD. Refer to City of Edmonds traffic control requireir&nts.
• Trenching within the City Right -of -Way is limited to 1001f,
INSPECTIONS
0 E-Engineering Final
PARTIAL INSPECTION DATE: INITIAL: NOTES:
PARTIAL INSPECTION DATE: INITIAL: NOTES:
FINAL INSPECTION APPROVED DATE: INITIAL:
A . . 6
ov EDAI
CITY OF EDMONDS
121 5TH AVENUE NORTH - EDMONDSWA 98020
PHONE: (425) 771-0220 - FAX: (425) 771-0221
PERMIT FEES/ RECEIPT
DATE: Wednesday, October 18,2006
PERMIT #: ENG20060471
PROJECT ADDRESS: 541 HEMLOCK ST, EDMONDS
PROP OWNER. BENTONIRENEJ
541 HEMLOCK WAY
EDMONDS, WA 98020
*FEESUMMARY.-
Descrip —Fee
gon
X-Permit Surcharge Fee
$15.00
$0.00
$15.00
E-Right ofWay Permit Fee
$160.00
$0.00
$160.00
E-Engineering Inspection Fee
$50.00
$0.00
$50.00
Total Due:
$225.00
$0.00
$225.00
*FEES ARE ESTIMATED BASED ON INFOkVfATION PRO VIDED AT SUBM17-TAL-SUBJECT TO CHANGE
PAYMFNT TRANSACTIONS:
TO BE BRIED PuMARTERVY