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® CiTY OF EDIPCX''3S
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APPLICATION
The City of EdmZR6 ET Fill for SIDE SEWER PERMIT EASEMENT NO . ................•--------------- -----------
NEW CONSTRUCTION REPAIRS LID No.
L 0 -----------
l�S
..................... ............ -------------------------------------------------------- CONTRACTOR ........................................................... OWNER . ....... ............ PERMIT NO.
JOB ADDRESS ------ Val LEGAL DESCRIPTION: LOT NO .............. 12-
......................... BLOCK NO. -------------------------------------
.................................................................. ---------------- ------------------------------------------------------------------------------
NAMEOF ADDITION .W.�.S--------------------- ... . .............................................. ------------------------------
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r %The City of Edmonds
r
APPLICATION
for
SIDE SEWER PERMIT
NEW CONSTRUCTION ❑ REPAIRS ❑
EASEMENT NO- --------------------------------------------
LID NO- ------------------ -ASMT. NO. ------------------
OWNER ---- .-•-----------------------••------•---- CONTRACTOR ---------•-•-•-•------•-------•-- PERMIT NO. ---•---••-----------
:.. 1. - �y
JOB ADDRESS _2---`-----------1--.----------.----C'''.'... . LEGAL DESCRIPTION: LOT NO. -.---. ------------------ BLOCK NO. ..........
------------------------------------------------------------------------------------------------------------------------------------------------------------------
NAME OF ADDITION .-. -!
Approved:
DATE
................................ BY............................................................
NOTICE:
No warranty of accuracy.
The information shown on the attached map(s)
was compiled for use by the City of Edmonds,
its Employees and Consultants. The City of
Edmonds does not warrant the accuracy of
anything set forth on these map(s). Any person
or entity requesting a copy should conduct an
independent inquiry regarding the information
shown on the map(s), including, but not limited
to, the location of any sewer stub shown. Such
sewer stubs may or may not exist and may or
may not exist at the location shown. Neither
the City of Edmonds nor its employees or
officers shall be liable for the information given
on map(s), nor for any one representation
provided based upon said map(s).
} CITY OF EDMONDS - SIDE SEWER PERMIT
WATER -SEWER D"ARTn>lEBM
PERMIT
rCall 775-2525 for side sewer inspections BEFORE covering any portion of the construction.
\Inspection will be provided within 24 hours after requst. NO Sat., Sun., or holiday inspections.1
ADDRESS LOCATION OF CONSMUcTION............. .......... �w.�'_
1. c
Ey� ..) -----•---...'?-es.. ! _...........................................
Y14SOP1=Y LEGAL DESCRIPTION-------�1-..I.-......�--2.»............... 1�—=�-�•-=�.>"�`�...._.�.�.r�„U..�. .._..
-----------••-----•-------------------*-----------------......------._......................
......._... _............. -..----•---........••---.... ...OWNER AND/OR BUILDER ...... ... .s .['�.i A ...........................
(*NTRACTOR'S NAME A DRESS.....--- .. ... - ..... -
- _......................................................
OII granted • ••--........... 1977-or repair and/or connection of a side sewer to the city sanitary sewer
m is acoordssce with City of Edmonds ordinances.
7t
,At-c:NTION IS CAUXD TO THE FOLLOWING:
ltOM No. 1—The owners of the property may obtain a permit to construct sewer inside property line. A licensed Side Sewer Contractor must be employed to construct
adds sewer 1n street area. Do not cover any portion of sewer before it has been inspected.
No, 2—All work performed in city right-of-way requires an Invasion of Right -of -Way Permit obtainable froin the City Engineer's office.
100M NO. 3—Obtain full information regarding Ordinance 11.16.030 and Regulations governing aide sewers when you get permit.
XV= No. 4—Top of side sewer 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.
X&M 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.
XWE No. 6—I1t is unlawful to alter or do any other work than is provided for in the permit, or to do any work an the main sewer or its appurtenances except to in-
sert the pipe into the wye. p
MAPPROVED [] Date --- ---- ...... By. .... .......... Date ........... ...... ..... �.B�yr�� DSte....... By ..............
APPROVED /bate...-.. = ,i� �'��r....--- By. - �✓�.�,�i
W-•...............................................------I-------......-----
Resnarks:.......-.....---•••......------
- BOTH Pe Copies MUST
— Be Signed By Owner of Firm Performing Construction PRIOR To Request For Inspection —
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"" , hereby certify that the side sewer installation constructed under this permit
Owner of Contracting Firm performing Construction)
ed in accordance with all governing ordinances of the City of Edmonds.
Datedthis ............... . ........... day of•- ........................................................ ---• 19
V Check BEFORE you dig for: Water E], Gas p, Telephone p, Power ❑, Sewer [], Other p V
&-_-..X,
C.
City of Edmonds
RIGHT-OF-WAY CONSTRUCTION
PERMIT
EET FILE Permit Number:
Issue Date: 6 ` 41` 7
A. Address or Vicinity of Construction: "% /O q,-- 11,4 cl J
B. Type of Work (be specifif ): =�1 � /<-�I e--og I
890_19y
Contractor: `tt 12 �' iJ P rvvl CIV' r Contact: Lill ` /1L1 t! L ivy nJ
Mailing Address: J Phone:
State License #: �i/ P-11-- :2- 9 Liability Insurance: Bond: $
D. Building Permit # (if applicable):
Side Sewer Permit # (if applicable):
E. ❑ Commercial ❑ Subdivision ❑ City Project ❑ Utility (PUD, GTE, WNG, CABLE, WATER)
❑ Multi -Fa ' }F Sin Family ❑ Other
INSPECTO : � INSPECTOR:
F. Pavement or Concrete Cut : XYes []No G. Size of Cut: � x Z, H. *Charge $
APPLICANT TO READ AND SIGN
INDEMNITY: Applicant understands and by his signature to this application, agrees to hold the City of Edmonds harmless from injuries, damages, or
claims of any kind or description whatsoever, foreseen or unforeen, that may be made against the City of Edmonds, or any of its departments or employ-
ees, including or not limited to the defense of any legal proceedings including defense costs, and attorney fees by reason of granting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL INSPEC77ON
AND ACCEPTANCE OF THE WORK. ES77MAYED RESTORA77ON FEES WILL BE HELD VN77L THE FINAL STREET PATCH IS COMPLETED BY
C17Y FORCES, AT WHICH 77ME A 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 Department ;W144
Work 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.
I have read the above statements and understand the permit requirements and the pink copy of the permit will be available
on site at all times for inspection purposes.
r r /
Signature: Date: c� [ / :z
(Contractor or Agent) rr
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
erd
APPROVED BY:.c' RIGHT OF WAY DEPOSIT:
TIME AUTHORIZED: VOID AFTER DAYS DISRUPTION FEE/FUND 111:
SPECIAL CONDITIONS: f RESTORATION FEE:
4 # ree PERMIT FEE
TOTAL FE
COMMENTS: RECEIPT N0:.
DATE::.. ISSUED BY;.,= -
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Engrg. Div. 1991
FIELD INSPECTION NOTES (Fund III - Route copy to Street DepE.)- '1
Comments:
Diagram:
CONTRACTOR CALLED FOR INSPECTION ❑ YES ❑ NO
Partial Work Inspection by P. W.:
Work Disapproved By:
FINAL APPROVAL BY:
Date:
Date:
Eng. Div. July 1985