21223 84TH AVE W (2)11111111111111
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21223 84TH AVE W
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PERMIT NO: 980
0 of Edmonds
I ity PERMIT EXPIRES
SIDE SEWER PERMIT
Address of Construction:
I
1z
Property Tax Account Parcel No. 7 y/ 17 "Aj rju I
Attach copies of all access and utility easement Verified and Approved b
Owner and/or Contractor: W R Qe!�6=e 9,
Contractor License 191D�Building -Permit K14_—
_4
,.�<ngle Family Invasion into City *Right -of W . ay�_ �Ves D No
F� Multi -Family (No. of Units *RW Construction Permit _1001 6
F� Commercial (No. of Units Cross other "Private Property: E] Yes AN_o
P , ic "Attach legal description and copy of recorded easement.
Owner/ ontractor
I*ner or contractor signature and acknowledgement statement: bate
y signing for this permit I certify that I have read the City's public handout entit ed
ide Sewer Specifications, and shall comply with all City requirements outlined therein.
9 CALL DIAL -A -DIG (1-800-47- 5555) BEFORE ANY EXCAVATION'W
W FOR INSPECTION CALL 425-771-0220 extensi4&i0a
24 HOUR NOTICE REOUIRED FOR ALL INSPECTION REOUESTS
NOTE: IF JOB SITE IS NOT READY FOR INSPECTION WHEN "
INSPECTOR ARRIVES A $45 RE -INSPECTION FEE WILL BE CHARGED.
Job Site Ready YES NO Date: Initial:
Partial Insp ection: Date: Initial:
Partial Inspection: Date: Initiair
FINAL INSPECTION APPROVED: Date: 06910* Initial:_,.l P As -built to Street File:
t, PERMIT MUIST'BE POSTED ON JOB,SITEf�
White Copy: File Green Copy: Inspector Buff Copy: Applicant
L;temp;bldg;forms;sspennitjlg4/00
APPLICATION
STREET FILE for
The City of Edmonds SEDE SEWER PERNaT EASEMENT No . ..........................................
NEW CONSTRUCTION [] REPAIRS 0
324-03600
OWNER............ Ri.chand ... Ri.tter ............................................................. CONTRACTOR -------------------------------------------------------------------------------------------------- PERMIT No . ......................
ADDRESS ....... Z1223 84th Avenue W. .................. LEGAL DESCRIPTION: LOT No . .............................................. BLOCK No . ............................................
............................................................................
NAMEOF ADDITION ............................................................................ ............................................................
Dye Tested On Sewer 1972
Approved:
DATE................................................ By ......................................................................
V
City of Edmonds Permit No: Z&4-4049/0
RIGHT-OF-WAY CONSTRUCTIONPERMIT IssueDate:
A. Address or Vicinity of Construction:
B. Type of Work (be specific): !S;J0 ts e L.,30-"x O-CL" llr�
C. Contractor: R'='n-TeK Contact: '/-Om
Mailing Address: :2CO 'S (n T1, e,& Phone: 00(c, :39(
State License Q 00f Liability Insurance: Bond: $
D. Building Permit # (if app licable): Side Sewer Permit # (if applicable): is�
E. F-1 Commercial El Subdivision [_1 City Project EUC (PUD, VERIZON, PSE, AT& T, OVWD)
Multi -Family El Single Family F1 Other
INSPECTOR:
F. PAVEMENT CUT: El YES *0 NO G. SIZE OF CUT X �P
CONCRETE CUT: KYES El NO
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 FOLLOW!NG THE FINAL
INSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES W?LL 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) 296-05-305 an I d 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 9EGINNING WORK
I HA VE READ THEA2B011E STA TE-MINTS AND UNDERSTAND THE PERMIT REQUIREMENTS AND ACKNOWLEDGE
E,
THATIMUSTM-41(E E PINJ9,M OF_WF.URMITA VAILABLE ON SITE A TALL TIMES FOR INSPECTIONS
Approved by: _JQL6
Time Authorizyed- Void -Aft*er 1,1212001,
Special Conditions:
Date:
Agent)
FOR CITY USKON Y
Right-of-way Fee:
Disruption Fee/Fund 111:
"Irm 9;' -44i � 1. - -
"FOU06- ler., r
?.rff otal Fee: 1 Z 76
Receipt No: LIZ,:
we Issued by:. T, 9&/"e!
MT-e -, A r4. 2 1 ALvF-c r-/orq% .0 � �w ryiw �r-,41 t4s 42 F, AfAi..
UPON COMPLETION OF PERMITTED WORK, AN- ENGINEERING FINAL
INSPECTION IS REQUIRED PER CHAPTER 18.00 OF THE EDMONDS
COMMUNITY DEVELOPMENT CQDE (Phone 425-771-0220, Ext. 1326)
FINAL APPROVAL OF PERMITTED WORK. A VVIO DATE: /z24A�q
42WInspector's Signature 19 /1
For insDectiofi
see
Information handout.
NO WOIZK SHALL BECIN I'MOIZ TO I'ElZMITISSUANCE
E!AMy Documents\Forms\Eng�mg\ROWpermit_.doc