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10212 240TH PL SW
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TAX ACCOUNT/PARCEL NUMBER: y� " V O�
BUILDING PERMIT (NEW
COVENANTS (RECORDED) FOR:
CRITICAL AREAS: DETERMINATION: ❑ Conditional Waiver ❑ Study Required ❑ Waiver
DISCRETIONARY PERMIT #'S
DRAINAGE PLAN DATED: V 1-
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
PERMITS (OTHER):
PLANNING DATA CHECKLIST DA
SCALED PLOT PLAN DA
SEWER LID FEE S: LID #:
SHORT PLAT FILE: LOT: BLOCK:
SIDE SEWER AS BUILT DATED:
SIDE SEWER PERMIT(S) #:
SOILS REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
FOR:
WATER METER TAP CAIM DATED:
_ 04
LATEMP\DSTs\Forms\Street File Checklist.doc
04/03/1997 08:23 2062351571 MURPH'Y ENTERPRISES PAGE 01
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Critical Areas Checklist CA File No: �� ��,rj
Site Information (soils/topography/hydrology/vegetation)
1. Site Address/Location: __1021 Z Zq 0`f 14 L • Sw
6�1 Property Tax Account Number: `-' E' s 5 SJ D — ay Z) — D / / — V 0
3. Approximate Site Size (acres or square feet): • 2 a �c RCS
4. _ Is this site currently developed? yes; no.
If yes; how is site developed? s INC, L E FA M t L\/
5. Describe the general site topography. Check all that apply.
t// 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
over. a horizontal distance of 33 to 66-feet).
Steep: grades of greater than 30% present on site (a vertical rise of 10-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 standing water: AJ jA ; Approx. Depth:
What season(s) of the year?
8. Site is in the floodway/VA_ floodplain_ of a water course.
9. Site contains a creek or an area where water flows across the grounds surface? Flows are year-round?
Flows are seasonal? (What time of year? ).
10. Site is primarily: forested ; meadow ;shrubs mixed
urban landscaped (lawn, shrubs etc)
11. - Obvious wetland is present on site:
2.
3.
Plan Check Number, if a plicable?
Site is Zoned? P 5'
SCS mapped soil type(s)?
For City Staff Use Only
4. Critical Areas inventory or C.A. map indicates Critical Area on site?
5. Site within designated earth subsidence landslide hazard area? / V %}
DETERMINATION
Reviewed bv:
IZ
WAIVER
#P20
-C. 1-6-7-
City of Edmonds
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: :' Z t l of
City Receipt #:
Critical Areas File #: G 20D'10l (P 5
Critical Areas Checklist Fee: $135.00
Date Mailed to Applicant:
A property owner, or his/her authorized 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.
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 harmless 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 famished by the applicant, his/her/its agents or employees.
By my signature, I certify that the information and exhibits herewith submitted are true and convect to the best of my
knowledge and that I am authorized t th� application on the behalf of the owner as listed below`.
SIGNATURE of APPLICANT/AGENT ""4 DATE
Property Owner'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 posting attendant to this a plica�,n.
i
ATURE OF OWNER / / DATE / '- —
Owner/Applicant:
�oy SJ31 R 14 L'An1 D
Name
-1021 Z LOT-4 PL 5W
Street Address
Applicant Representative:
t L--C (-Om
Name
PO (6?? 3f z 28'
Street Address
ED MON 0Y ,yJ 0 ZO , b jq 18103
City C. State Zip City State Zip
Telephone?.V 5-4 Z — q66 7
Email address (optional):
Telephone: 2-06 ` s � 7 —93 q-
Email Address (optional):
a
. City of Edmonct
RIGHT-OF-WAY CONSTRUCTION
PERMIT Permit Number:
Issue Date:
A. Address or Vicinity of Construction: 02r TO
B. Type of Work (be specific): S �i4 Lf� DR6 161 P1 P _
M aN SWALE S
C. Contra 0' : `( E�I~� PR 15 C- � Contact: , ��,.MURPRY
Mailingi
ss:/�,� �E �LLEWEPhone: i -
State Li: ��� fE09 0L- Liability Insurance: f 5 Bond: $ D. Buildingt # (if applicable): Side Sewer Permit # (if applicable):
E. ❑ Comme' al ❑ Subdivision', YE]i._Cit`y Project ❑ Utility (PUD, GTE, WNG, CABLE, WATER)
❑ Multi -Fa 'ly ❑ Single Family ❑ Other
f
INSPECTOR: ; r' ' INSPECTOR:: t;
A� A p
F. Pavement or CoArete Cut : ❑ Yes ONO G. Size of Cut: is H� C�}l $a
APPLICANT TO READ AND SIGN
INDEMNITY: Applicant undo stands and by his signature to this application to hold the City of Edmonds harmless from injuries, damages, or claims of any
kind or description whaisIT ver, foreseen or unforeseen, that may be made against the City of Edmonds, or any of its departments or
employees, including or not li ited to the defense of any legal proceedings including defense costs and attorney fees by reason of granting this permit.
THE CONTRACTOR IS RESPg S/BLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL INSPEC- .
TION AND ACCEPTANCE OF : E WORK. ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREET PATCH IS COMPLETED
ti
BY CITY FORCES, AT WHICH T E A DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT.
Two sets of construction ditwings of proposed work required with permit application. .�
A 24 hour notice is requirea,',for inspection. Please call the Engineering Division, 771-0220.
Work and material is to be i s ected during progress and at completion.
Restoration is to be in accord ce with City Codes.
Street shall be kept clean at al �imes.
Traffic Control and Public Safd shall be in accordance with City regulations as required by the City Engineer.
All street cut trench work shall be atched with asphalt or City approved material prior to the end of the working day;
NO EXCEPTIONS.. �
I have read the above statements and u erstand the permit requirements and the pink copy of the permit will be
available on site at all times f r inspect' n urposes.
Signature: �- C-rz, e- Date.-
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK ,
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE Egg. Div 1997
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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).