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RECEIVEI
AUG 3 2012
OF
,;a
Ax ti, APPROVED BY P ING
6TRLE
7 FILE
--'- ( 6 t. -�`
City.of EdImonds
Development Services Department
Planning Division
Phone: 425.771.0220
Fax: 425.771.0221
The Critical Areas Checklist contained.on this form is to
be filled out by any person preparing a Development
Permit Application for the City of. Edmonds prior to
his/her submittal of the application 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).
Date Received:
City Receipt #:
Critical Areas File
Critical Areas Checklist Fee: $155.00
Date Mailed to Applicant: '7-0-/,A
A property owner, or his/her authorized representative,
must fill out the checklist I sign and date it, and submit it
to. the City. The City will review the checklist, make a
precursory site visit, and' make a determination of the
subsequent steps necessary to complete a development
permit application.
Please submit a vicinity map, along with the signed copy
of this form to assist City,staff in finding and locating the
specific piece of property described on this form. - In
addition, the. applicant shall include other pertinent
information (e.g. site. plan, topography map, etc.) or
studies in conjunction with this Checklist to assistant staff
in completing their preliminary assessment of the site.
The undersigned applicant, and his/her/its heirs, and assigns, in consideration on the processing of the application agrees
to release, indemnify, defend and hold the City of Edmonds harmle'ss from any and. all damages, including reasonable
attorney's fees, arising from* any action or infraction based in whole or part upon false, misleading, inaccurate or
incomplete information fumished by the applicant, his/her/its agents or employees.
By my signature, I certify that the information* and exhibits herewith submitted are true and correct to the best of my
knowledge and that I am authorized to file this application on the behalf of the owner as listed below.
SIGNATURE OF APPLICANVAGENT
11M. T4 10
Property Qwner's Authorization
By my signature, I certify that I have authorized the above Applicant/Agent to apply for the subject land use application,
and grant my permission for the public officials and the staff of the City of Edmonds to enter the subject property for the
purposes of inspection and pq
shng-attqidant to this application.
SIGNATURE OF OWNER
DATE
'V
Owner/Applicant: Applicant Representati*e:
�J
Name, Name
5 3
Street Address
F
city State Zip
Telephone: c�o6 `�63-q337
- (, I o 5 4cr (9 5 e(,4+ (v-,
Email address (optional): i0e-
Street Address
City . State Zip
'Telephone:
O—A
Vm-a-il Address (optional):
Revised on 9114110 P20 - Critical Areas Checklist.doc
Page I of 2
#P20
Cra -L 0 1 -Z, 004,V"=7
5itLi Information (soils/ topo
1. Site Address/ Location:
Critical Areas Checklist
grdphy/ hydrology/ vegetation)
1) -2�,3 9-",' Afe-
2.- Property Tax Account Number:
3 Approximate Site Size (acres or square feet):
4. Is this site currently developed?, Xyes; — no.
If yes; how is site developed? re 5
5. De�ibe the gene . ral site topography. Check all that apply..
Flat: less than 5-feet elevation change over entire site.
Rolling: slopes. on site generally less than 15% (a vertical rise of 10-feet over a horizontal
distance of 66-feet).
CA File No:
005 2-(D 00000 76-6
Hilly: 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-feei).
Steel): grades of greater than 30% present on site (a vertical rise of 1.0-feet over a horizontal
distance of less than 33-feet).
Other (please describe):
6. Site contains areas of year-round standing water: Approx. Depth:
7. Site contains areas of seasonal standin g water: --li 0 Approx. Depth:
What season(s) of the year?
8. Site is in the flo.odway Afo floodplain /1/0 . 'of a water course.
9. Site contains a creek or an area where wator.flows across the grounds surface? Flows are year-round?
Afo Flows are seasonal? _ (What time of year?
10. Site is primarily: forested meadow ;shrubs mixed
urban'landsc aped (lawn, shrubs etc)
-11. O�viouswetlandds_presenton . site:.. Alb
— - - - — --- - -------- - -- - - - ----------- For City Staff Use Only
1. Plan Check Number, if applicable? 4A
2. Site is Zoned? PIS - co
3. SCS mapped s-bil type(s)? %a - LA&-_j�ec s.-&.nC&
4. Critical.Areas inventory or C.A. map indicates Critical Area on site? No
5. Site within designated earth subsidence landslide hazard area?
SITE.DETERMINATION
STUDY REQUIRED WAIVE.R'
------ natp. /10
Revised on 9114110 P20 - Critical Areas Checklist. doc Page 2 of2
APPLICATION
for
The City of lEdmonds SEDE SEWER PERMIT
NEW, CONSTRUCTION REPAIRS r-1
I
OWNER ................................................................
. . . ........ ............
7-�
ADDRESS ... ........................
.. ........ .......... ... .........
% � VD
EASEMENT No..
CONTRACTOR ... W�16 ....... * ------ *,,* ............... * .............. PERMIT No.(�
LEGAL DESCRIPTION: LOT No . ............................................. BLOCK No. ............................ ..........
NAME OF ADDITION ....... Azoelry (:,. ")
................ ...........................................................................................................
APPROVED
MAY 2 1967
e. P iq
(E7
OW Approved: 0 -Aj
--;:> .............................. ...........
DATE AP ........ ............ BY '7�ok". -
-:,�_C,1,TY OF -EDMONDS
Cl.-VIC:. ENTER: _'WATER -SEWER. DEPARTMENT
SIDE SEWER PERMIT
Call rRospect, '6-1107-.'w4en work
Is ready, for Inspection. (No. inspec,
tions Saturday, 'Sunda�y or holidaid.) 21-72
ADDRESS.................. 63.3 ---- - --- 2nd ... Ncr--*-h ............................................................................
.....................................
0. H. Granmo Russell Johnson.
OWNER... .................................
CONTRACTOR ......................................................
.........................
May 2, 67
Permission Is granted ............................................. 19 ......... for ....... I ................. days to REPAIR'or CONNECT a side sewer
with City Se%-�ers In accordance With application on file- and governing ordinances.
ATTENTION IS CALLED TO THE FOLLOWING:
NOTE No. I —The owners of the property may obtain a Permit toDonstruct sewer inside property line. A. licensed Side Be . wer Contractor must
be employed to construct side sewer in street area. co not cover any portion, of sewer- before it has been inspected.
TTOTE No. 2—Obtain full information regarding Ordinance 11.16.030 and Regulations governing side sewers when you get permit.
NOTE No. 3—Top of side sewer must have at least. 30 In hes coverage at property line and 1 . 2 in I ches, . Inside I property line; minimum grade of 2%.
No bends In grade sharper than % will be 'Permitted.
NOTE No. 4—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 rimy develop within one year of completion.
NOTE No. 5--It 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 appur-
tenances except to Insert the pipe Into the wye.