632 GILTNER LN.PDFiiiiiiii iiiiii
11398
632 GILTNER LN
2ITY OF EDMONDS
PUBIJC WCPXS — ENGINEERIWj
ACTION REPORT
N? 4164 -,
SUSPENSE DATE:
Date: Time: File #
Attachments: Yes
10 No
SUM�CT:
Ck-
TOR: NAME:
A
ADDRESS:
PHONE:
REQUEST RECEIVED BY:
TELEPHONE
CONTACT IN 1111I./-<=
OTHER: =
RECEIVED BY
WMITP Tn
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ACTION
All Concerned Notified
Action Completed/File
CITY OF EDMONDS SIDE SEWER PERMI-r
WATER -SEWER DEPARTMENT
PERMIT
Call 775-2525 for side sewer inspections BEFORE covering any portion of the construction.1
Inspection will be provided within 24 hours after requot. NO Sat., Sun., or holiday Inspections.1
ADDRESS LOCATION OF CONSTRUCTION_ 6_1 Thi rd ArqnamA Orri:',
...... 2 .................................................. 2 ................................................ ........................................................
PR - OPERTY LEGAL DESCRIPTION ... lAt-.1L ... Tn n� I Vcv� e�5, tAJ
. ...... r .........................................................................................................................................................
.............................. * ------ * --------------- OWNER AND/OR BUILDERA ... TACOUT
.............................. . .................................. . .......................................................
................... * ............... ** --------- - ------ * ----------------- * ------------------------------------ * ------------ * .................. * --- - -------------- ---- * ------------------- * .................................................... * .........
i Backhm S�,rvic(�, 24096 - 92nd Ave. NI., Edr-ionds
CONTRACTOR'S NAME & ADDRESS ... P..n. ... b ..... A.1;31 ................ �t .............................................. . .................................. . .......................................................
Permission Is granted ----------- I ..... ...... . ........... 1 19.34, for repair and/or connection of a side sewer to the city sanitary sewer
s in accordance with City of Edmonds ordinances.
4
ACTION IS CALLED TO THE FOLLOWING:
NOTE No. 1—The owners of the property may obtaln a permit to construct sewer inside property line. A licensed Side Sewer Contractor must be employed to construct
side sewer In street area. Do not cover any portion of sewer before it has been inspected.
NOTE No. 2—All work performed in city right-of-way requires an Invasion of Right -of -Way Permit obtainable from the City Engineer's office.
NOTE No. 3—Obtain full Information regaxding Ordinance 11.16.030 and Regulations governing side sewers when you get permit.
NOTE No. 4—Top of side iewer must have at least 30 inches coverage at property line and 12 Inches inside property line; minimum grade of 2%. No bends In grade
sharper than % will be permitted.
NOTE No. 5--Trenches in street must be water settled and surface of street restored to original condition. Contractors shall be responsible for failure due to improper
work which may develop within one year of completion.
NOTE No. 6_ t is unlawful to alter or do any other work than is provided for in the permit, or to do any work on the main sewer or its appurtenances except to in-
Iert the pipe into the wye.
DISAPPROVED Date Af . ................... By ................ Date ....... B ................ Date ............... . ................... . By ................
Dat .... .......................................................................................
APPROVED 10 _11 ...... -7 BY ... I... I
Remarks: ....... . .. ................... . ...........................................................................................................................................................................
..................................................................... . ........................................................................................................... ................ _ .......................................... .........
BOTH Permit Copies MUST Be Signed By Owner of Firm Performing Construction PRIOR To Request For Inspection
I
........... .................................................................. .... hereby certify that the side sewer installation constructed under this permit
(Owner of Contracting Firm Performing Construction)
'nstalled in accordance with all governing ordinances of the City of Edmonds.
Dated this ......... 13 ............. day of .................. . .. ......................... 19.7f.
V 4 Check BEFORE you dig for: Water F], Gas [], Telephone E], Power F], Sewer E], Other C] V -V
October 2, 1972
File No.-4,08
LEGAL DESCRIPTION FOR HARRY GILTNER
PARCEL GC
The Westerly 100-00 feet of the, . Easterly 343.00 feef of that por-Hon of Government
Lot 2 in Section 24.. Township 27 North, Rlange 3 E-ast, in Snohomish Countyi,
Washington, described as follows: Beginning at The Norl-heast corner of said
Government Lot 2; thence We.st for 30.00 feet; thonce South for 30.004eet, to.tho-
co�ner of the paved. rodi and Seventh Avenue North produced in the -City of Edmonds;
thence S 0*12100"W, ---,!c)ng ihe West I ine of Seventh Avenue North produced -for 233.67-
-hence N 89'39100"W, aforl(�,'
feet'fo the True Point of Beqi,'nning of this doscripflon; I
a line -drawn parallel will, the- Norl�h line,of said Govornment Lot 2 for 611.'07,feot
to an Intersection with the Easterly margin of Third Avenue North; thence S 29*18t00"W,
along -said Eastetly margin for 86.85 feet; thence S 89*39"00"E,' for 653.71 feet to an
Intersec-l-ion with the Vlesi' line of Seventh Avanue, N�ori-h produced; thence N 0'12100"E,
along said West line for 76.00 feet to the True Point of Boginning.
EXCEPT that portion -1hereof conveyed to the City of. Edmonds for street ri ght-of -way
by deed recorded under Auditor's File- No. 2270223, records of Snohomish County,'
Washington.
of E 1),V
4 0
Un
CITY OF EDMONDS
121 5TH AVENUE NORTH - EDMONDSMA 98020
PHONE: (425) 771-0220 - FAX: (425) 771-0221
41
*PERMIT MUST BE POSTED ON JOBSITE*
STATUS: ISSUED ENG20080130
SIDE SEWER PERMIT (1-Single Family)
Permit Number: ENG20080130 Expiration Date: 6/3/2008
Job Address: 632 GILTNER LN, EDMONDS
�APPLICANT CONTRACTOR
THOMAS DORAN SOUTH COUNTY PLUMBING
632 GILTNER LN PO BOX 6157
EDMONDS, WA 98020-3001
EDMONDS, WA 98026
425-775-7377
LICENSE #: SOUTHCP 19302 EXP: 8/22/2008
*
*
JOB DESCRIPTION
REPAIR N PROPOSE TO REUSE LATERAL LIDNUMBER.-
CRINDER PUMP N I PROPOSE TO REUSE SIDE SEWER
SIDE SEWER REPAIR
LAS EMENT tiN FO RNIATION
•
PROJEC7 CROSSES OTHER PRIVATE PROPERTY
•
VERIFICATION OF RECORDED EASEMENTS COMPLETE
1ADEMATTY. The Applicant has signed an application which states helshe holds the City ofEdmonds harmlessfrom injuries,
damages or claims ofany kind or description whatsoever, foreseen or unforeseen, that may be 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
atiorneyfees by reason ofgranting this permit.
CALL DL41,A-DIG (1-800-424-5555) BEFORE ANY EXCAVATION
CALL FOR INSPEMON (425) 771-0220 EXT. 1326
24 HO UR NOTICE REQUIRED FOR ALL INSPECTION REQUESTS
THIS APPLICATION IS NOT A PERMT UNTIL SIGNED BYTHE CITY ENGINEER OR HISMER DEPUTY: AND FEES ARE PAID, AND RECEIPT IS ACKNOWLEDGED IN
SPACE PROMDED.
A Pvinted: Thursday, Aprd 03, 20(
q1310
$kjol��ECOPY XINSPECTORCOPY E] APP11CANT COPY
STATUS: ISSUED
ENG20080130
• Refer to City of Edmonds Side Sewer Information handout for approved pipe materials, inspections and other requirements.
• A 6" cleanout with 12" locking cast iron laniphole cover is required at the property fine.
• Maintain 10'separation between the sanitary side sewer and the water service line.
• Applicant shall repair/replace all damage to utilities or frontage improvements in City fight -of -way per City standards that is
caused by or occurs during the permitted project.
* E-Sanitary Side Sewer Inspection
PARTIAL INSPECTION DATE: INITIAL: NOTES:
PARTIAL INSPECTION DATE: INITIA L: NOTES:
FINAL INSPECTION APPROVED DATE: INITIAL:
City of Edmonds
Plumbing & Mechanical, Tank & Demolish
Permit Application Form C
Site Address: ('_ -S a a � � �_ V.,
Suite#:
Business/Tenant Name (if applicable):
PROPERTY OWNER:-!'N
Mailing Address: -2
Tax Parcel #:
I
OV ED
01,
city: State: �'j Zip:_ C;l
Phone: -7 FAX: E-Mail:
CONTRACTOR:
C,\ c�S -7
Mailing Address: _� c) ?_�
City: S_ State: Zip:
Phone: (1-12_;�) -7?S-- 73 2_2 FAX: E-Mail:
State License Number: Exp: Date: City Business License No: WAb4—
,2bO,-rl4 a P I I-50;a (A),AA
MECHANICAL
-7 PLUMBING
Fixture Type
Fixtures
Total
Fixture Type
Fixtures
Total
Gas Fu mace/Fi replace:
Water closet
BTUs Location
Sink
Gas logs/direct vent fireplace
Lavatory
BTUs Location
Tub/Shower
Air Handler BTU Location
Dishwasher
a Electric
Hose Bib
a Other
Gas water heater w/expansion tank
Boilers _BTUs Location
_BTUs Location
Hydronic Heating
Expansion Tank
Vents, Single Duct #
Floor Drain
Other:
Pressure reduction valve
Water Service Line =ft
Gas Piping ft
Other:
# of Outlets
DEMOLITION sqft
Gas Outlets
TANK _gallons
0 AC Unit 0 Furnace
0 Fill Material
0 Water Heater a Boiler
0 Pump, Rinse & Cap
0 Dryer a Stove/Range
0 Removal
a Fireplace a BBQ
Critical Area Chklst
0 Other Gas Outlet
0 Study Reg. 0 Waiver
L:\TEMP\BUILDING\WEBchecklists\MECH.PLUMB.APP.doc 8/31/06 55 1?'fla /'�—
R.TREEN
I m lum 4
NAME: PukrAW9 tgs�t,3
PROJECT ADDRESS: -RECEIPT DATE:
PROJECT
FILE PROJECT REVIEW CHECKLI I ST
REVIEWED
B : Initia
Dme)
PLAN.
WATER
-COMMENTS
FIRE
BLDG.
SEWER
STREET
ENG.-
Setbacks/Variance/Setback Adjustment
Conditional Use Permit
ADB Requirements
Other Zoning Requirements
.4
Underground Wiring Required
-------- - - - - - - -
Lot Slope 15%
-.6
SEPA Environmental Checklist/Hydraulics Permit
. . . . . . . . . .
. . . . . . . . - - - - - - - - - - - - - - - - -
7.;
Tree Cutting Plan
. . . . . . . . . . .......
...........
. . . . . . . . . . . .
Plat/Subdivision Requirements 57-4-11
:9:
Legal Description Verification 5-el-171
. . . . . . . . . . . . . .
Quit Claim/Street Dedications
........ --------
- - — - - - - - - - - - - - - - - - - - - - - - - - - - -
Easements - Public/Private
Engineering Storm Drain Review Fee
a
Engineering 2.2 Inspection Fee
Drainage Plan (On -Site)
Setback - Top of Bank, Stream, WaterZourses
g
...............
I . .. "'. `�
05 M
A m -.1
Setback - Storm Drain Line
Open Ditch - Existing
AS -
Culvert Required
10 41,20
F,_-.4 9
Culvert Size
:Aon
Shoulder Drainage/Shale Open Runoff
. . . . . . . . .
Catch Basin Required
- - - - - - - - - - - - - - - - - - - - --------------- - - - - - - - - - - - - - - - - - - - - - - - -
............
Driveway Slope & Vehicle Access OZ--
I DO
. . . . . . . . . .
.........
Sidewalk Required
.
Curb & Gutter Required
- - - - - - - - - - - - - - - - - - - - - - - -
. . . . .
Curb Cut For Driveway Re uired
lop
Street Paving Required
1 27.
Right -Of -Way Construction Permit Required
Street Name Sign Required
29
Other Signing Required
�.�30
Bond Required For Public Improvements
FEMA Map Check/Water Table
32
Side Sewer Availability
. . . . . . . . . . . . . .
.
............
...... .
3
Calculate Sewer Connection Fee If No* LID # .
...........
34:
Create Street File
...... . . . . . . ..... ......
Existing Water Main'Size
Water Meter Size
Service Line Size
Water Meter Charge Required
F, x,
Hydrant Required
.................. ........ . . . . . .
. . . . . . . . . . .
4 0
Hydrant Size Existing
. . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . .
. .. ...........
41
Fire Line Charge Required - Sprinkler
42
Street Cut
. . ... .. ..
.. ...
T�
43
Miscellaneous
.
44
Reviewed By:
FIRE PLANNING ENGINEERING WORKS
"T FILE
5- 1 T-f-- FL-4�
-gVJ7— (5 / Z rl'1,6 R A ^16
41
4' DiA. TIGHTLINE
TO CATCH BASIN
DOWN SLOPE
EXIST. HOUSE
L
&�; '. &7"
RECEivEr)
�511011 MAR 2 9 1993
PERMIT COUNTER
DRIVEWAY APRON
SHALL CONFORM
TO CITY STANDARD
DESIGN REQUIREMENTS PI.A(
LIGHT POLE
PROPERTY LINE u
CONTROL C.B'.� WASHED AGGREGATE Driveway, z L
TYPE 1, CB 15 CONCRETE SURFACE -a�rCONCRETE.
PAVEMENT
t __v
42 LF, .5% MIN. S
DETENTION PIPE, dLECT.
1 0
18" DIA. N- 12 ADS, EXISTING PAVED SERVICE
PE SURFACE TO BE ENTRANCE I
ui REMOVED
0 z
Z :is
i Proposed
Residence
ui
ui IV)
0 0 0
cc 1cr
ju cc
0.
LLJ
Lu
INLET C.B.,
%D TYPE 1, C.B. 15
4' DIA. TIGHTLINE '!�;' 00
FROM DOWNSPOUT
COLLECTOR AND D/W
DRAIN
DATUM POINT:
TOP OF CONCRE
VAULT EL. 100'-0"
E WATER METER
EXIST.
FLFCIRIJC_
VAULT
E OF ROOF
OVERHANG ABOVE
EXIST. GTE
UNDERGROUND
VAULTS.-YER FY LO(
EXIST. HOUSE -
rrr,. T
IUAVEv%
7 EXIST. HOUSE
FILE
EXIST. HOUSE EXIST. HOUSE
APPLICATION
11
The City of Edmonds for � EASEMENT NO . .....................................
SIDE SEWER PERMIT
NEW CONSTRUCTION REPAIRS F� LID No ASMT. NO - ------------------
OWNER C) �4
.............................................................................................. CONTRACTOR ---------- --------------- --_---_--------------- PERMIT NO - ----_-------------
-t� -Tt
-c= CD
JOB ADDRESS .... LE6AL DESCRIPTION: LOT NO - ----------------------------- w -------- BLOCK NO.--.-: ----------------------------------
40
uj
!lu
ME
................................................................................
, C_j %.- %_ I
..................................................................
Approved:
DATE ........
........ By ---------------
"71 /11ft-0 -----------
APPUCATION
11
The City of Edmonds for . EASEMENT NO - --------------------------------------------
SIDE SEWER PE"Aff
NEW CONSTRUCTION REPAIRS F] LID NO - ----- ------------ ASMT. NO - ------------------
--------------------------------------- ........ PERMIT NO.
bVNER ........ ------- -- ---- ------------ ----------------------------- CONTRACTOR --F -------
JOB ADDRESS ----- ��ig ---------- 3 -- -------------------------- I ------------------ LEGAL DESCRIPTION: LOT NO - ------ j ----------------------------- BLOCK NO - ------------------------------------
DATE
BY---------------------------------------------
STREET FILE*
CITY of EDMONDS --- PUBLIC WORKS DEPARTMENT
Routing of Building Permit Applications
Proposed Property Address of Application: 632 - 3rd Avenue North
DEPARTMENT
COMMENTS
DATE
V A T E R
S T R E E T
S E V.E R
N 0 T E S
BUILDING
DEPARTMENT COMMENTS
'. '11 r. I b. �
n
onni
'4
02
04
BUILDING DEPARTMENT Applicant Fill
Inside Heavy Lines
PERMIT APPLICATION
U or, PERMIT
ZONE NUMBER
JOB
ADDRESS
& .3 C�
NAME (OR NAME OF BUBINESS)
MAII ING ADDRESS
PERMISSIBLE 7, ACTUAL
LOT COVERAGE LOT COVE'ROAGF
PFR.NIISSIBLE Hl!',IGIIT PROPOSED HEIGHT
0
CITY TELEPHONE NUMBER
�7 ;74�r
AC`TUAL LOT AREA TOTAL BLD-G. AREA 1z
REQUIRED YARDS PR,)FIOSEn YARM�
FRONT SiDE REAR FRON r SIDE REAR
NAM
ADDRESS
LEGAL LOT VARIANCE OR CONDITIONAL USE
C] YES NO PERMIT NUMBER
PLANNINn DEPT. APPROVAL DATE:
CITY
TELEP14ONE NUMBER
STREET R/W
EXISTING STREET R/W.. ..FT. DEFICIENCY TIIIH PROPERTY
COMP. I'LAN ST. R/W _147. ....... Fl,.
z
i
0
N AM I-1,
-1 t iWZR K _8
ADDRESS
CHECKED BY
CITY
4TA
TELEPHONE NUMBER
METER SIZE
SERVICE SIZE
CLEARANCE
CHECKED BY
.9 F LICENSE NUMBER
CITY LICENSE NUMBER
REMARKS
Legal Description of Property (Show Below or Attach Four Copies)
TYPE CONNECTION
VERIFIED BY
PERC. TEST
PERMIT NUMBER
09
REMARKS
FIRE ZONE
TYPE OF CONSTRUCTION
STREET IMPROVED
I C] YES NO
SPECIAL INSPECTOR REQUIRED
[] YES 0 NO
OCCUPANCY GROUP
I
GAS
NEW RESIDENTIAL LINE
NON-RESIDENTIAL SIGN
ADD RETAINING
DEMOLISH El WALL
A LTER EXCAVATE FENCE
F OR FILL ( x Ft
REPAIR PRE -MOVE swim
1:1 INSP. POOL,'
PLAN CHECKED BY THIS SITE IS LOCATED IN THE CITY
OF EDMONDS. LOCAL SALES TAX
SHOULD BE CODED 31.04.
REMARKS
NUMJiER OF STORIES
NUMBER OF
DWELLING
UNITS
NAT JRE OF WORK TO JAE DONE
Plan Check No ...............
Valuation
Fee
Recelpt No.
BUILDING
PROPOSED USE
PLUMBING
HEAT & GAS LINE
PLOT PLAN (Indicate Building setbacks, abutting streets)
0 1914
FENCE
SION
RETAINING WALL
SWIMMINO POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
E
8 9 0 - I C) C) -
�7 A;�7 f'% N�"
STREET FILE
City.of Edmon&
RIGHT-OF-WAY CONSTRUCTION
PERMIT Permit Number. 95- /'3
Is -sue Date: 61 - 30 - 'Ps -
A. Address or Vicinity of Construction: 632 Giltner Ln ( 9519483
'r
B. Type of Work (be specific): Inata.11 Service
C. Contractor: - Washington NaturAl Gas
"'Mailing Address: 1122 75 St SW Everett
State License #: 98203
D. Building Permit # (if applicable):
Contact: Frank Swan
Phone: 447-3284
Liability Insurance: Bond: $
Side Sewer Permit # (if applicable):
E. El Commercial EJ Subdivision El City Project [3[ Utility (PUD, GTE, WNG, CABLE, WATER)
n Multi -Family Single Family F1 Other
INSPECTOR: INSPECTOR: WA;4c--H
F. Pavement or Concrete Cut: R] Yes 0No G. Size of Cut: x H. Chargi�,$
cut
APPLICANT TO READ AT�kSJGN
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 of any legalproceeding8 including defense Costs, andattomeyfee8 byrea8onofgrantingthi8Permit.
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 TIMEA DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT.
Construction drawing 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 above statemenq�d understand thepermit requirements and thepink copy of thepermit will be
available on site at all t7le 4Tr-inspPctiofz d4woses.
Signature: Date:
(Contractor or Agent)
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY:
TIME A I UTHORIZED:,VOID,AFTER Au(A 3b— DAYS
SPECIAL CONDITIONS: A-
60h g
COMMENTS:
-RIGHT OF WAY DEPOSIT
DISRUPTIONFEE/FUND III:,
RESTORATION FEE:
PERMIT FEE:
_-TOTAL FEE:
RECEIPT FEE:
DATE:
ISSUED BY: �'
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE Eng. Div. 1994
FIELD INSPECTION NOTES
Comments:
Diagram.:
(Fund 111 - Route copy to Street Dept.)
CONTRACTOR CALLED FOR INSPECTION El YES
Partial Work Inspection by P.W.:
Work Disapproved By: Date:
FINAL APPROVAL BY: Date:
0 NO
A--
Washli-awl
N mt
at ral Gas
AWa,IwiqIrxibx,iqy(rxv4),-vN Addendum to: City of Edmonds
Right of Way
Permit Application
Submitted by: Mariamne Kingsbury
Engineering Aide
Washington Natural Gas
1356-7500 X7596
Key:
Watermain depth -G-
-SS-
gas main -&
0
-9 4 12$ -2-1
Water
Gas
Sewer
Water hydrant
Water valve
Washington Natural Gas Company
1122 75th Strect S.W.. F%-crett. Washington 98203. (206) 355-3331
CA FILE NO.
Critical Areas Checklist
Site Information (soils/topographyjhydrp I etation)
1. Site Address/Location:
2. Property Tax Account Number: i�`) Z)
3. Approximate Site Size (acres or square feet):
4. Is this site currently developed? k1l no.
If yes; how is site developed?
5. Describe the general site topography. Check all *9 apply.
Flat: less than 5-feet elevation change over entire site.
� If 4 � 2 tlYJ ,
J U L 14 1994
PER'V'IT C-0,1J.-NITER
Polling: slopes on site generally less than 15% (a vertical rise of 10-feet over a
horizontal distance of 66-fect).
Hil1r. 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 on site (a vertical rise of 10-feet over a
horizontal distance of less than 33-feet).
Other (please describe):
6. Site contaCm areas of year-round standing water: Approx. Depth:
7. Site contains areas of seasonal standing water. Al I/ ; Appr9x. Depth.:
What season(s) of the year? NO
8. Site is in the floodway floodplain of a water course.
9. Site contains a cr ellor an area where water flows aqm the grounds surface? Flow§ are year-
round? C) Flows are seasonal? (What time of year?
10. Site is p(imarily: forested meadow _; shrubs mixed
urban landscaped Qawn,shrubs etc)
11. Obvious wedand is present on site:
P"01/0494
ar 90-19'
City of Ednon&
Critical Areas Che c*klist
The Critical Areas Checkiist contained on
this form is to be filled out by any person
preparing a Development Permit
Application for the City of Edmondsprior
to histher submittal of a development
permit 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 from -
observations of the site or data available at
City Hall (Critical Areas inventories, maps,
or soil surveys).
An applicant, or his/her representative,
must fill out the checklist, sign and date it,
and submit it to the City.. The City win.
review the checklist, make a precursory site
visitt; and malm a determination of the
subsequent steps necessaryto, complete a
development permit application.
With a signed copy of this form, the
applicant should also submit a vicinity map
or plot plan for individual lots of the parcel
with enough detail that City staff can find
and identify the subject parcel(s). In
addition, the applicant shall include
other pertinent information (eg. site
plan, topography map., etc.) or studies in
conjunction With this Checklist to assist.
staff in completing th6w preliminary
assessment of the'site.
I have completed the attached Critical Area Checklist and attest that the answers provided are
factual' to the best of my knowledge (fill out the appropriate column below).
Own pplicant: Applicant Representative:
p ican
N=e Nam
Stree Ad&=
City, State, ZIP Phone
Signaftue Date