6828 174TH ST SW.PDF111111111111
1036
6828 174TH ST SW
STREET FILE
City of Edmonds
Critical Areas Determination
Applicant: Charla & Keith Jensen Determination #: CA-92-56
Project Name: Permit Number:
Site Location: 6810 174th St. S.W. Property Tax Acct #: 5131-000-1
Project Description:
New signal family residence
Waiver Criteria (all criteria must be found to apply):
xx There will be no alteration of the Critical Area or its required buffers;
xx The development proposal will not impact the Critical Area in a manner contrary to
the goals, purposes, objectives and requirements of the Critical Areas ordinance;
xx The development proposal meets the minimum standards of the Critical Areas
ordinance;
xx The above findings are based on the following conditions of approval:
1. The applicant must follow all steep slope regulations required by the
Building Official
Based on ' the above findings and conditions, the requirement for a Critical Areas Study
associated with this development permit is hereby Waived, as authorized by Chapter
20.15B. 150 (B) of the Edmonds Community Development Code.
Name Signature Date
6,90 - 19" -
Gq of Edmoiids
Critical Areas Checklist
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 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 ftom 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 will review
the checklist, make a precursory site visit,
and make a determination of the subsequent
steps necessary to complete a development
permit application.
With a signed copy of this form, the
applicant should also submit a vicinity map
of the parcel with enough detail that City
staff can find and identify the subject
parcel(s). In addition, the applicant is
encouraged to include any other pertinent
information or studies in conjunction with
this Checklist to assist staff in completing
their 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).
Owner / Applicant: Applicant Representative:
Ad- r s'?
Narne Narne
Title Title
44L ' /
Street Address
City, State, ZIP Phone
C),
Signature Date
Street Address
City, State, ZIP . Phone
Signature
Date
Critical Areas Checklist
Site Information
Project Name: 7J—,e,, 1 41, Permit Number:
Site Location: �910 17il �sV4 Property Tax Account Number: 5'1 000 Z15 -0 50,)-
Approximate Site Size (acres or square feet): 16OW&
Have you filled out a Critical Areas Checklist for a'project on this site before?
General Site Conditions
1. Has the site been cleared or logged? Date of most recent action:
Soils / Topography
2. In the Snohomish County Soil Survey, what is the mapped soil type(s)? A I t4tr !Sapdy
3. Describe the general site topography. Check all that apply. ?OZZ"
stopl-s
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.)
Hilly: slopes present on site of more than 15% and less than 30% ( a vertical rise
of 10 feet of horizontal distance.)
Steep: grades of greater than 30% present on site.
Comments
--/'
Hydrology egetation
4. Site contains areas of year-round standing water:
5. Site contains areas of seasonal standing water: --Approx. Depth:
6. Site is in the floodway floodplain f a water course.
al—1
7. Site contains a creek or an area where water flows across the grounds surface? &JO -flows
are year-round? -A:) —Flows are seasonal?
8. Site is primarily: forested meadow ;-shrubs mixed
9. Obvious wetland is present on site:
10. Wetland inventory or map indicates wetland present on site:
11. Critical Areas inventory or map indicates any Critical Area on site: -;d
-- — ----- City Use Only—
................
............
STUDY REQUIRED: Critical areas study is required.
CONDITIONAL WAIVER: Critical areas study not required if specified conditions satisfied.
WAIVER: Critical areas study is not required.
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Determination Numbe Reviewer IJL--/
Plarmer Date
Rey 3127/92 CAD
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The City of Edmonds Side Sewer Drawing EASEMENT NO . ................ ............ .............
NEW CONSTRUCTION F1 REPAIRS F� LID NO . ............... ... ASMT. NO. ...........
OWNER------ 1-?,%AJtA ...... D ...... .................... CONTRACTOR --------------------------------------------------------------- -------------------- PERMIT NO - --------------------
JOB ADDRESS ----- G.8.2,8 ----------- 1-74.-r - - ------------------------------ LEGAL DESCRIPTION: LOT NO - -------------------------------------- BLOCK NO - ------------------------------------
PWW-0001-1 1/75 (REV.1 1/78)
---------------------------------------------------------------------------------------------------------- .......................................................
NAMEOF ADDITION ---------------------------------------------------------- ............................................................
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Approved:
DATE............................................ By - ..............
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CITY OF EDMONDS
PUBLIC WORKS DEPARTMENT
RIGHT - OF - WAY CONSTRUCTIONzAREET FILE
A. *Address or vicinity of Construction
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Owner: 4-16— Ac
Name
Mailing Address
City, State, Zip Code
Contractor: —
Name
Mailing Address
1', AIAI. 4 �11V-
city, State, Zip Code
Permit No.
Issue Date
0 Permit Issued To:
Type of Work to be Done: 7—h,�A,,tl
rl;� -)A= 1el
0 Work in Connection With:
El Sub or Plat & Single Family
0 Comml. / Ind. El Apt. Condo.
9 Pavement Cut: El Yes Z No
State License Number
7
Telephone Number
* * NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE * *
B. APPLICANT TO READ AND SIGN
INDEMITY: 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 it's 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 or 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 site for inspection purposes at all times
I I J
Signature: -- 41 X 1/4
6wn�e�ror Agent
te
THIS PERMIT MUST BE POSTED AT THE JOB SIT FOR INSPECTION PURPOSES
CALL DIAL - DIG PRIOR TO BEGINNING WORK
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C. issued By: .P, .L-e
Time Authgr'iied: 'Void' after days
Special Conditions:
Ammcndments:
Permit Fee:
Security Deposit:
Receipt No.:
Fund 111 Fee:
Street Cut Dimensions
X
* *. NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE * *
Eng. Div. December 1978
Encr. Div. December 1978
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ENVIRONMENTAL ANALYSIS
EXEMPT UNDER DISTRICT SEPA
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DATE RELEASED
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W.O. NO.
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ENVIRONMENTAL ANALYSIS.
EXEMPT UNDER DI$TRI CT SEPA
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INTERPRETATION- REFER"RED,TO:
DATE BY,
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!�*R-OFFICE COMMUNICOONS
DATE —A ril 18 79
/STREET FILE
TO UTILITY BILLING FROM BUILDING DIVISION
FORM 41 - LITT
SUBJEOT:
CHANGE OF ADDRESSES
Glenn Granger 6802-174th St. S.W. to 6828-174th St. S.W.
kobt. Holt Bldg. 202 to 226 Dayton St.
Church,of Open Bible evidently has never had a number
so it will be 204-6th Ave. qo.
A-C
Thanks
. Ann
W
ism
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BUILDING DEPARTMOR
Applicant Fill
USL WIRMIT
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PERMIT APPLICATION
Inside Heavy Lines
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ADDRESS
NAME (OR NAME OF BUSINESS)
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STREET/UTILITY WORK REQUIRED
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PERM IT FOR WORK IN PUBLIC R/W
K YES
NO
LEPHONE NUMBER
UNDERGROUND WIRING REQUIRED
VYES
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CONNECTION TO SANITARY SEWER
YES
NO
SEPT�C TANK PERMIT REQUIRED
DYES
V:NO
SEPT C TANK PER.MIT NO.
SEE MEMO DATED
:- —
LEPHONE NUMBER
REMARKS
CITY LICENSE NUMBER CHECKED BY
Below or Attach Four Copies) METER/S,17E BUILDING SUPPLY SIZE
SIGN A'REA ENV. REVIEW
ALLOWED I PROPOSED 1COMPLETE1 EXEMPT
REMARKS
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NUMBER OF
REMARKS
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NATUR OF WORK TO BE DONE
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"Applicant, on behalf of his or her spouse, heirs, assigns and
SIGN
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_j successors in ' interest, agrees to indemnify, defend and hold harmless
2 the Ci(y of Edmonds, Washington, its officials, employees, and
RETAINING WALL
agents from any and all claims for damages of whatever nature,
I arising directly or indirectly from the issuance of this permit. Issu-
SWIMMING POOL
ADI3 NO.
:)RELINE
PLANNING REVIEW BY DATE
ILOT COVERAGE
SIDE A.151REAR
7—
ONSTRUCTION CODE [HEIG77
AREA OCCUPANCY OCCUPA
I GROUP I LOAD
THIS SITE IS LOCATED IN THE CITY
OF EDMONDS. LOCAL SALES TAX
SHOULD BE CODED 31.04.
VALUATION I FEE
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0 i :trice o f 1his permit shall not be deerned to modify, waive or reduce
L. llol hillit III ally way lite
'.0 C. I S91
121 5TH AVENUE NORTH - EDMONDSWA 98020
PHONE: (425) 771-0220 - FAX: (425) 771-0221
*PERMIT MUST BE POSTED ON JOBSITE*
STATUS: ISSUED ENG20070087
I RIGHT OF WAY PERM IT (7-EUC Standard)
Perrait Nmiber: ENG20070087 Expiration Date: 6/28/2007
Job Address: 6828 174TH ST SW, EDMONDS
COMCAST OF WA, LLC
1525 75TH AVE SW
EVERETT, WA 98203
Location:
LICENSE #: EXP:
JOB DFSCIZIPTION
Request pennission to open trench/bore 24'in shoulderofROW to evend and bury CATVservice drop to 6828-174th St. SW.
DIS IZUPTION INFORMATION
ASSESSED VALUE: $0.00 PROPERTY AREA: 0
SIDEWALK: (OXO) DURATION IN MONTHS: 0 FEE: $0.00 STREET DISRUPTION TRENCH CUT: 0 X 0
PARKING: OX0 DURATION IN MONTHS: 0 FEE: $0.00 YEAR OF OVERLAY: 0 FEE: $0.00
ALLEY: OX0 DURATION IN MONTHS: 0 FEE: $0.00
IADEMATTY- 7he 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
attorneyfees by reason ofgranting this permit.
THECONTRACTOR IS RESPONSIBLEFOR WORKMANSHEP AND MATERIALS FOR A PERIOD OFONEYEAR FOLLOWING INEFINAL
INSPECTION AND 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
rmterial prior to the end of the workday- NO EXCEMONS.
Three sets of construction drawings of proposed work are required with the pennit application.
CALL DIAL -A -DIG. (1-800424-5555) BEFOREANY EXCAVATION
CALL FOR INSPECTION (425) 771-0220 EXT. 1326
24 HOUR NOTICEREQUIRED FOR ALUINSPECTION REQUESTS
THIS APPLICATION IS NOTAPERMITUNTIL SIGNED BY THE CITY ENGINEER OR HISMER DEPUTY: AND FEES ARE PAID, AND RECEIPT IS ACKNOWLEDGED IN
SPACE PROVIDED.
BY
bA-
Printed: Tuesday, April 17
F� FILE COPY I 21<SPECTORCOPY F� APPLICANT COPY
STATUS: ISSUED
ENG20070087
• Restore ROW to City standards
• Restore Landscape to like or better conditions.
• Call for locates of underground utilities prior to any excavation.
• Alert affected residents and/or businesses prior to work start.
• Conform to approved working drawings and Traffic Control plan'.
• Public utilities maintain 5'separation fi-omCky 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 l0am-6prn. No work on Sundays or Federal Holidays.
• Call for required inspections as noted.
I INSPUCTIONS
• E-Traffic Control
• E-Engineering Final
PARTIAL INSPECTION DATE: INITIAL: NOTES:
PARTIAL INSPECTION DATE: INITIAL: NOTES:
FINAL INSPECTION APPROVED DATE: INITIAL:
6828
r.T.W1 I
CATV PE
N
Private driveway
Open trench in shoulder of ROW 24 ft
Comcast of Edmonds
1525 75th Street SW
Suite 200
Everett, WA 98203
Contact: Kermit Benson 425-263-5362
North Drop
Node: EM05A
6828 174 ST SW- City of Edmonds
RF,3PCfMS13,LE FOR
0'0-�,ITROL AM' DRAINAGE
!,pp-,'.J0V2--D AS NOTED
LNIGHM ER;NG
Work Details
Open trench in shoulder of ROW 24 ft, extend and bury CATV service drop to 6828 174 ST SW
Total footage 24 ft
Install cable at 36" depth.
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All disturbed areas will be restored to existing or better conditions.
Backfill material will be mechanically compacted to 95% of maximum density as specified by the City of Edmonds. In tight
corridors hand trenching will be utilized to ensure protection of other utilities. Contractor must locate all existing utilities impacted
by this project.
Please see attached plans for restoration, erosion control and traffic control. Erosion control will consist of placing filter fabric fence
and/or sandbags along curbs and catch basins where necessary. Keep drainage system clean and functioning. Remove all debris
from the work site. Streets and roads will be cleaned both during and after installation of work.
City of Edmonds Permi
7
RIGHT-OF-WAY CONSTRUCTION PERMIT Issue Date:
'A. Address or Vicinity of Construction:
B. Type of Work (be specihc)-,
Q r 6 M / -:5 c� 0
C. Contractor: Co n*tact: k e v i V)
Mailing Address Wood 4ilic W Phone:
State License #:
Liability Insurance: Bond: $
D. Building Permit # applicable): Side Sewer Permit # (if applicable):
E. F� Commercial D Subdivision El CityProject EUC (PUD, VERIZON, PSE, AT& T, OVWD)(0ffi0J1_
J :F� Multi -Family El Single Family El Other
INSPECTOR:
F. PAVEMENT CUT: El YES 96 NO G. SIZE OF CUT x
CONCRETE CUT: YES WNO
A131'LICANT TO 11l,Al) ANI) SICN
INDEMNITY. Applicant understands by his/her signature to this application helshe holds the City of Edmonds 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 but not limited to the defense of 'any -legal proceedings including defense
costs and attorneyfees by reason ofgranting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLORING 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 THE APPLICANT.
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 possession.
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 DIAL -A -DIG (1-800-424-5555) PRIOR TO BEGINNING WORK
I HA VE READ THE ABO VE STA TEMENTS AND UNDERSTAND THE PERMIT REQUIREMENTS AND A CKNO WLEDGE
THA T I MUST MAKE THE PINK COPY OF THE PERMIT A VAILABLE ON SITE A T ALL TIMES FOR INSPECTIONS
Signature:,
or Agent)
'710 - 07
Date: j2ol
FOR CITY USE ONLY,
Approved by: Right-of-way Fee:
Time Authorized: Void After Disruption Fee/Fund Ill:
Special Conditions: Restoration Fee:
Total Fee:
Receipt No:
I S
wedby:
UPON COMPLETION OF PERMITTED WORK, AN ENGINEERING FINAL
INSPECTION IS REQUIRED PER CHAPTER 18.00 OF THE EDMONDS
COMMUNITY DEVELOPMENT CODE (Phone 425-771-0220, Ext. 1326)
FINAL APPROVAL OF PERMITTED WORK.
For inspection requirements see
DATE:
inspector's Signature'
Inspection Information handout.
DAMy Documents\Forms\Engnmg\ROWpermit—.doc
Ccomc a*st
PROJECT'S TrMELINE AND PROPOSED HOURS OF OPERATION:
Timeline — Up to 30-days past the issue date.
Work Hours —The entire project area will be conducted from 7:00 AM to 7:00 PM or
as specified by the Inspector.
Traffic Control Plans
1. The standards and guides of the latest version of the MUTCD or as set-up per
Code shall be followed at all times.
2. A copy of the Permit and Traffic Control Plan shall be on -site with all
contractors during the project.
3. All contractors will avoid parking on sidewalks and shoulders and will take the
lane and follow the proper traffic control set-up for the given situation.
4. Pedestrian access shall be maintained through or detoured around all work
sites.
5. Please find attached the traffic control plans for the various types of work
sites that will be encountered during our project.
6. Flaggers will be used only when all other methods of traffic control are
inadequate to warn and direct drivers. Only licensed flaggers will be used on
the project.
7. If situations occur when questions arise about proper traffic control set-up the
solution will be determined in the field with the Comcast Construction Rep.
and the Inspector.
C
.6 tib
Ei6sidn*: n I Rides #L;
If curb and gutters in project area:
• Filter bags will be placed in catchbasins; downstream of work site, and
• Small check dams of pea gravel filled sandbags will placed within the
gutter upstream of the catchbasin.
Traffic control set-up for minor encroachment
Traffic control set-up for lane closure
FLAGGER STMIN
001.
BL9
100,
02ce
FL"GER STAPON
L
Depth, Cleaning, Containment,
Compaction, and R e''S''toration
Depth = - �
4
36-inch minimum
Compatible w/
other utilities
Shoring required
at 4-ft +
Pavement Cuts
4,
T-cut I -ft wider
than trench
Neat -line saw -cut
or jack hammered
edge ,
All trench backfill shall be mechanically
compacted to 95 percent of maximum density
using 1-ft loose lifts with whacker or 2-ft loose
lift with a hoe pack.
If proper compaction cannot be achieved with the
native material, new import material is required at
the 95 percent rate.
As an alternative, CDF can be used in a design
mixture approved by the Engineer.
0
Ccomcast
CLEANING: All Streets and roads are required to
be cleaned and swept both during and after the
installation work.
* Mechanical Vacuum is preferred method
CONTAINMENT: All un-restored shoulders or
material storage areas are required to be contained
with reflective barricades.
All disturbed.areas shall be restored to
existing or better conditions.HHH!
Trench parallel to road:
4 Shoulder - Match existing surface conditions
Pavement - 6 1/2 inches of crushed surfacing material
and asphalt concrete Class B at 2- inches minimum or
same thickness if greater..
-Trench across road (immediate cold mix patch):
; Asphalt - Permanent hot mix patch at same thickness
or 2-inches and sealed within 30 days.
Concrete - saw cut and pored with mastic joints, eight -
sack mix, either type 11 of III cement, within 30 days,
I
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9
Date_2-7--I�J
MEI-10 TO: "Building Division
-Community Development Department
FROM: .En ineering Division
Puglic Works Department
SUBJECT:;
=Cr, Al <f
After review of the subject building permit application, we have the
following.comments':
Coordination of the, location of any structure with respect to
utilities, streets, property lines and driveway grades is the
responsibility of the,contractor.
The contractor is required to keep the abutting streets cleaned
of dirt and debris caused by the construction.
The "Right -of -Way Construction Permit" is required, from the
Engineering Division of Public Works, for any work -within the
Public Right -of -Way or public easement.
_�g Driveway slope not to exceed 14%.
Connection to sanitary sewer required.
-7 Septic Tank Permit required, submit design.
/_7 Fire hydrant required, submit design.
-7 Site drainage per code # %pIZq See approved plans
L-7 Curb Sidewalk
V7 Paving required.
Bond required.for public improvements. Sub
mit cost estimate.
Underground wiring required.
Approved Engineering Plans required when applicable.
1:7
-berg —P.E.
For F. ITe7rz
City Engineer
Department of Public Works
Rev. 7/78
0
Z
*PUBLIC .1,,-ORKS DEPAM1ENT CHEC�* 0- 7- 79( Date
BUILDING PERMIT REVISI
7 ".5 r,5
&Z.Address
Street Right-of-Way'Existing
ao , REQD
Access Easements Existing YO 5 _�5-/ - 2,e UQD
Utility Easement Existing YS,:> REQD
Lot per Subdivision Plat Assessor Map
Site Plan Checked for Accuracy -7- -7
Underground Wiring Reqd.
Check Accuracy of.Legal Description -7-1 rl
Environmntally Sen"si.ti've Area KJ A
Environmental Checklist Reqd.
Flood Hazard Zone I
Shoreline Management Area
Slope, Soil, Vegetation
Stream, Creek, Drainage Basin
Exis ting Zoning,Per Code
Amenities Design Board Approval - Reqd. `r-40 ADB # Approval
Board of Adjustment Ap oval Reqd.
,)I Review- -By Date:' 771 7
<% Exi-sting 1,,Tater Md:in Size
Water Main Reqd.
Service Line Reqd.
Hydrant Size Existing -
Hydrant Reqd. Per Fire Code IYA .,Size
Detector Check Meter Reqd. IYA
Cross Connection Inspection NA
Fire Department Comnents
Water Meter Charge Reqd. 3 3-20 1'!
.4 Revieu, -by-: Date: A 7 -Z �7
Ir Septic T sl I pro
Septic Tank Permit Reqd. Permit No. KI
Sanitary Sewer Availability Proj. L I
el
Drawing No. File No. LIQ VA
Side Sewer Availability
�Wo Sanitary Sewer Connection Fee Req�. NJ
_M1
PON Review By: Date:
(�)en Ditc1i Existing
,r�eqd.
Culvert Reqd.. Size
Catch Basin Reqd. Indicate on Site Plan
0 Shoulder drainage n-taintain collecuion On s-wale open rLu ioff
'-'vinhol.e rccid. A/,--�. Indicate on Site Plan v
Soil Conditions and Ground WaLer Field Cliecked
Z�,
Revic�,,7 by DO to7,
1),SCreet Paving,Reqd..
g
Curb and Gutter Reqd.-
Sidewalk Reqd.
C�urb Cut for DriVeway Reqd._,
T4 Rie)it-of-Way Construction Peni-tit Reqd
Bond Reqd. for -Public Inprovc-m--n ts— AAuzl
vStreet Nai-,)e Sign Reqd..
Ocher Signing Reqd.
:Pre Permit Site Ins.peccion M- (Le ()1_1
BY: SLIER
WATER
V)�
SITUT T
ENGINIETFUNG
0
W�
C14
Specj.'�*11 Rcqu-ire-,-,-.enLs listed J-11 mal-o to C, Op" I a I Lrlit--.y Developi-mant Departii-ent,
Building Di\d-sion-
Date
All itcm-s filled in on Buildin.. Permit Application
By— Date
J.civq "?�Z3 LIULUJU an OU La L
By
I ; '.,,; 1 1% 1) '1-
)I.-01,70C] b)' PLI',)li.0 1-Jorks Dep�ai-U,,Y,,,1L:
RCM.Sed: 1-v 1-0-1977
Date