621 OLYMPIC AVE.PDF11111111111111
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621 OLYMPIC AVE
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STREET FILE
October 23, 1979
ME�,MO OF RECORD
On june 12, 1979 at approximately 8:00 p.m., City Water
Division crews were called out to repair a water mainnat-,
621 Olympic Ave�. After a short time, repairs were made and
the area cleaned UD. At this time it was not evident of
any damage to the address submitting a claim.
I
In as much as it was an emergency, the City Water Division
crew made the repair in the quickest �ime possible, trying to
keep any damage at a minimum.
Earry Ogl-e—,7—
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140TICE
Claim MUST b'e presented to the City Council and filed with the City CltiZ�-I!ji�hin 120 days
RECEIVED
from the date of Accident or Accrual of Damages.
TO THE CIV COUNCIL OF THE CIT'i OF M40UW: 0 C T 10. 1979 OCT 111979
_,Ylr- U1 I-LMIC; V'Vurl�s
PLEASE TAKE NOTICE, THA f). _ e - Edmonds City Clerk
(if married, give husband's name)
WHO NOVI RESIDES AT L 2. 1 Aa
(State presenV actUal address by street, number and city)
AND WHO FOR SIX I'MOIrIHS PRIOR TO DATE OF ACCIDENT HAS RESIDED AT
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(Givq� rpsidence by street, number and city)
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CLAIMS DAMAGES OF A14D FROM THE CITY OF ED140N.DS IN THE SUM OF' n .2 0 0 * . . .
arising out of the following circumstances:
Describe Clain., giving 0J- 44A,('/tAAN(1J1 L9 9,
DATE and TIME injury or —J
damage occurred, PLACE -till,
and full particulars.
Accurately locate and
describe defects caus-
ing injury or damage
and all acts of negli-
gence claimed.
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Accurately describe
injuries or damage e4lut.4il iTA-,j
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State items of damage
claimed. Itemize all 4 N)
expenses and losses.
op
(Claim must be sworn.to by claimant)
k5ignature of Claimant)
SU35C,RIBED AND SWORN TO /// — / .
before me this __day of e, 119
Notary Puilfc in and for the St_pte of
Washington, residing at
The City of Mmids
APPUC*fM
for
SIUDE SEWER PERIM
OUTSIDE QP- INSIDE Et-' REPAIRS 0
CARD No . ........ ....... ......... .. ---
EASEMENT No . ....... ................... - ....
OWNER .... 4 ..........
.... ...... .................. ....................... CONTRACTOR ...
........ PERMIT No.
STREET
HOUSE No . ........... ......... .... ................ AVENUE LOT No. ........... BLOCK No . ....................................
........ ....... tkLa�.... 1117 .........................
. ............ ........... ........
ui NAME ADD .......... .......
............
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Date
BACKFILL WORK ORDER ISSUED.,
SEWER WORK ORDER ISSUED ......
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Approved:
........ DEPOSIT, $ ......................................................
DATE..k.A�nt.l.i�ll.�:...-I��..e..� ............. BXT— 4-'t—
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The City of Edmonds
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APPLICATION CARD No . ......................................
for
SIDE SEWER PERYaT
OUTSIDE E] INSIDE E] REPAIRS E] EASEMENT No . ......................................
....................... PERMIT No.
OWNER --------- ........ ------
.. ... .... ... ....... -------------------------------- CONTRACTOR ....... ......
STREET
Z' ........................... AVENUE LOT No . ...................................................................... BIA>CK No . ...............................................
HOUSE No . .......... - ------- . ............ ----------------
NAMEADD . ............................................................................... . ............................................................................
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Date
BACKFILL WORK ORDER ISSUED ....................
SEVVER WORK ORDER ISSUED ---------------------------
Approved:
........... DEPOSIT, $ ....... ........................ i ...........
........... DATE ................................................ By ...................................................................
City of Edmo2a
City Engineer's Office
COMPLAINT REPORT
STREET FILE
Report No.
Referred to for Action J. Conway Time 11:15 amDate 12/3/68
Received By— L. Collins Time 11:15 amDate 12/3/68
Made By Mrs. Hill Address- 621 Olympic Ave. Tel. -PR 6-2350
How Received: Letter xxx Telephone In Person
Nature of Complaint: Basement flooded through gc�rage doors. Inadequate storm
drains, etc. RmKx Reconstruction of Olympic Ave. would probably take care of
the problem.
Describe Action Completed: Mr. & Mrs. Hill were advised that an asphalt hump-(-5-or 611
high) in front of garage doors would prevent flooding of basement.
Time Date 12/3/68 Completed By .7_14_ r,,w,;g
Location Sketch:
Permit No: ,
City of Edmonds 02
RIGHT-OF-WAY CONSTRUCTION PEIMIT fisue Date:
I V
C. VQ
A. Addiess oiNicinity-of Construction::
7.1
specific): -t
B;; T (be'
yp f W6�k
Ck_ S
I I o o
C. Contractor: C_ Contact:
6 Mailing Address: 'r Phone:
State Licenq --.Liability..Insurance:-Y-�-S--..- -5 n $ Q
D. Building Permit # (if applicable): Side Sewer Permit # (if applicable):
E.. -41 Commercial EJ Sul�division Ej City Project EUC (PUD, VERIZON, PSE, AT& T, OVWD)
F1 Mulei-Family Single Family Other
INSPECTOR:
F. PAVEMENT CUT. E:I'YES NO'. G. SIZE OF QUT,.� x
CbNtR&E CUT: ONES NNO,
�0
AA
ICANT TO, 1) SIGN
Al'I'L IMAI) AN
INDEMNITY. Applicant 'understands b�. his/her signature to this application helshe.. holds the City of Edmonds harmless,fibin
injuries, dqmages.or,claims of any, kind_or descri tion whatsoever, foreseen or unforeseen, ihat may be made against the City of
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Edmon& or any of its'dopartments or employees,,.,including but not limited to the defense of any l9gal proceedings including defense
costs andiattorneyfees, reason ofgranting this fiermit.
THE CONTRACTOR IS RESPONSIBLE,J�OR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLORING THE FII.VAL
INSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES 07LL-BE HELD UNTIL THE FINAL STREET PATCH IS
COMPLETED BY CITY FOR St.AT WHICH TIME A DEBIT OR CREDIT W!LLBE PROCESSED FOR ISS NCE,770�T]�EAPPLICANT,
U4
Traffic�.control and p6blic safety shall be IiAn accordance with City regulation's as required by the City Engineer.' Every-
quired hy,(
.*&r-must be 'trained as�,,i� WAQ .296-155-305 and must have certification verifying completion of t'e
re W�d trainingin their pc�session.*
Restoration is to -be in acc6r�aance With'City codes. All street -cut trench work shall be patched with asphalt or City -
approved material!prior, to the, 6nd'of the workday — NO EXCEPTIONS.
Three sets of co'nstr�ctio.n drawings of proposed work are,required 'with the permit application.
CALL DIAL -A -DIG (1�800424�6555) PRIOR TO'BEGINNING'WORK,1
IHAVEREAD THE ABO VE- STA TEMENTS AND.:UNDERSTAND,THE PERMIT REQUIREMENTS-ANDACKNO.:.
Tffl T I U$YAfAkE THE P1XK"C6PY,6kT-HEPERM[T' AIVA ILABLE ON SITE AT A L L -TZ4ESJ76R`
Sigdatu sffk�� Date:
(Contractor or'XCent)
FOR CITY USE, ONLY,,.
Approved by:. &Gbe7zr Right-of-way, Fee: 1� 0 1
Time Authoelized:,Void After Disruption Fee/Fund 111:
Special Con. Aido-ns: 1) W WX 0
�W)A" Restoration Fee:
A LL NA I
"'Receipt No:
I &fOPLMDO 111-QtIQV13�Z6 Issued b
.-.UPON COMPL- ETION OF PERMITTED WORK, A ENGINEERING FINAL.
-REQUIRED'PER
:ANSPECTION, IS CHAPTER48.00 OF THE. EDMON
6
COMMUNITY'D -(Phon"e-425'7 011109�11i.
EVVELOPMENTCODE 71 -
PERMITTED -
-ALAPPi? OVAL:,
J4N
OF,
DATE�',
Inspector's Signature,
For inspection re*quirements see lngineefing'In'spection Information handout.
DAMy Documents\Forms\Engnmg�RQWpermit_.doc