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10121 241 ST PL SW
ADDRESS:
TAX ACCOUNT/PARCEL NUMBER: OMFODOD001--OC-)
BUILDING PERMIT (NEW STRUCTURE):
COVENANTS (RECORDED) FOR:
CRITICAL AREAS: DETERMINATION: ❑ Conditional Waiver ❑ Study Required ❑ Waiver
DISCRETIONARY PERMIT
DRAINAGE PLAN DA
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
PERMITS (OTHER):
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED:
SEWER LID FEE $:
SHORT PLAT
SIDE SEWER AS BUILT DA
SIDE SEWER PERMIT(S) #:_
GEOTECH REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
WATER METER TAP CARD DATED
OTHER:
LID #:
LOT:-g 11: BLOCK:
L:\TEMP\DST's\Forms\Street File Checklist.doc
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City of Edmonds PERMIT NO:
PERMIT EXPIRES — s
SIDE SEWER PERMIT �
Address of Construction: P LID #
Property Tax Account Parcel No.
Attach copies of all access and utility easementsVerified andOOApproved by
Owner and/or Contractor: Reg 6,1 ?bkb, Lj
Contractor License #: P_F_S,(_ut_ k 0 O`p Q7 VI AOM9 Building Permit #:
Single FamilyInvasion into City *Right -of Way: ❑ Yes XNo
❑ Multi -Family (No. of Units *RW Construction Permit #
❑ Commercial (No. of Units ) Cross other **Private Property: ❑ Yes No
❑ Public **Attach legal description and copy of recorded easement.
`Own ontractor _ � al A�
Owner ntractor signature and acknowledgement statement: Date
By signing for this permit I certify that I have read the City's public handout entitled
Side Sewer Specifications, and shall comply with all City requirements outlined therein.
W CALL DIAL —A —DIG (1-800-40-5555) BEFORE ANY EXCAVATION W
W FOR INSPECTION CALL 425-771-0220 extensionlIZ
24 HOUR NOTICE REQUIRED FOR ALL INSPECTION REQUESTS
. Job Site Ready YES. NO - Date: Initial:
Partial Inspection: Date: Initial:
Partial Inspection:
cc 0 `� �A-etCl_ LL Dater Z itial:�.a�_
FINAL INSPECTION APPROVED: Date:. �l c Ze'J�Initiah: . - As -built to Street File:
15 PERMIT MUST BE POSTED ON JOB SITE t�
White Copy: File Green Copy: Inspector Buff Copy: Applicant
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241 PL SW
CITY OF EDMONDS SIDE SEWER AS- BUILT
:::) ADDRESS HOMEOWNER
to 10121 - 241 PL SW
CONTRACTOR SCALE
RESCUE ROOTER LLC NTS
DATE DJR4VM PERMIT
03/29/2005 BY S I B RE L 03/30/2005 NO. 9979
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).