1022 3RD AVE S.PDFiiiiiiiiiiii
4925
1022 3RD AVE S
ADDRESS: " d s
TAX ACCOUNT/PARCEL #:
BUILDING PERMIT (NEW STRUCTURE) #:
COVENANTS (RECORDED) FOR:
CRITICAL AREAS #:0:5_ j27 DETERMINATION: ❑ Conditional Waiver ❑ Study Required giver
CRITICAL AREAS #: DETERMINATION: ❑ Conditional Waiver ❑ Study Required ❑ Waiver
DISCRETIONARY PERMIT #'S:
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORD FOR:
PERMITS (OTHER — list permit #'s):
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED:
SEWER LID FEE $:
LID #:
SHORT PLAT FILE:
LOT:
BLOCK:
SIDE SEWER AS BUILT DATED:
SIDE SEWER PERMIT(S) #:
GEOTECH REPORT DATED:
STREET USE/ENCROACHMENT PERMIT #:
FOR:
WATER METER TAP CARD DATED:
OTHER:
L:\TEMP\DST's\Forms\Jana's Street File Checklist 5-14-08.doc
CITY of EDMONDS �-E SEWER P R�,IT
L.. - For Inspection Call 771-320T EE FILE PERMIT,No.... 07920
Address of Construction:
Property Legal Description (Include all easements):
4a T�®C/C �Cdc��H ��4��G �a�1*ion
Owner and/or Builder: i'il(A
Contractor & License No: U E
Si ng1e. Family Residence EDMONDS R EC E i V E D
TREATMENT PLANT
Multi -Family (No. of Units ) CT 26 1988
Commercial (No. of fixture Units ) PUBLIC WORKS
Invasion into City Right -of -Way: No Yes (If Yes, Right -of -Way
Construction Permit required. Call One -Call -Center (1-800-424-5555) before any
excavation.)
Cross other Private Property: No /! Yes (If Yes, easement required,
attach legal description and county easement number.)
PLEASE READOTHE ITEMS LISTED ON THE BACK
J
certify that I have read and shall comply Date
ith the items listed on the back.
Permit Fee: Q •
Trunk Charge:
Assessment Fee:
1.Issued By:
iDate Issued:��—
Receipt No.:
Partial Inspection:
Comments Date Initial
Final Inspection Approved:
° Date Initial
oRejected:
Reason Date Initial
v
a�
** PERMIT MUST BE POSTED ON JOB SITE **
a�
White Copy - File Green Copy -'Inspector Buff Copy - Applicant
f-
The City of Edmonds Side Sewer Drawing EASEMENT NO_ ----------------- ___________________________
k NEW CONSTRUCTION REPAIRS ❑ LID NO ................... .ASMT. NO. .-----------------
OWNER--•--•-•----------------------------------------------------------------------------------•----. CONTRACTOR .. D- !� �" ..... 4' w---•--- -`--- WC ------------- PERMIT NO. 0-19..4% D
JOB ADDRESS ..� d� ------ V-------- .:........... LEGAL DESCRIPTION: LOT NO. -------- a---------------..._.__- BLOCK NO. ---- �-----.-------.----..--...
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------------------------------------------------------------------------------------------------------------------------------------------------------ ------------
NAME OF ADDITION �-S` \.\A---740----------------------------------------------------------------------
Udo ate.
CID
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r�rt t 3a' ' R
PWW-0001-11/75 (REV.11/78)
Approved: �+
DATE �---1=".0 S.----------
EDMONDS
TREATMENT PLANT
City oftdmonds
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 Devel'opmerit
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).
DateReceive-c : T
City Receipt#: c�1 lOS
Critical Area"s.File #:
Critical Areas Checklist Fee: $45.00
Date Mailed to Applicant:
A ,property owner, or. his/her authorized representative,
musf fill 'out the checklist, sign' and date it;' and submit it
to the City. The. City. will reyiew 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 fording 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 furnished by the applicant, his/her/its agents or employees.
By my signature, I certify that the information and exhibits herewith submitted are true and correct to the best of my
knowledge and that I am authorized toy file this application on the behalf of the owner as listed below.
SIGNATURE OF APPLICANT/AGENT 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 application. ,
Owner/Applicant:
Name
Street Address
21mff_c�q S d2C7
City State Zip
Telephone: a2 5 ` % 7S - a�59
Email address (optional):
DATE all n
Applicant Representative:
Name
Street Address
City State Zip
Telephone:
Email Address,(optional):
Critical Areas Checklist.doc/3.19.2001
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STREET FILE OA'
CITY OF EDMONDS, WASHINGTON
COVENANT TO PARTICIPATE IN/WAIVE RIGHT TO PROTEST LID
WHEREAS, the undersigned owners are the owners of certain real
property located in Snohomish County, Washington, which is legally
described on Exhibit A attached hereto and incorporated herin by this
reference as if set forth in full, hereinafter referred to as "the
property," and
WHEREAS, the owners have
6A4 *ES- SN�le- r*g. if". ( i n s e r t
impact on
applied to develop the property as
development type), which will have an
1,9/10e5F u/,44/< Iroo 7
nsert impact e. ., storm rainage, streets, water, sewer ,and
WHEREAS, as a condition of approval of the proposed development,
the City has required the owners to mitigate impacts of the development
and the owners and the City have agreed that such mitigation may take
the form of participation in a local improvement district (LID) for
construction of certain improvements deemed necessary to mitigate the
impact, now, therefore,
FOR AND INCONSIDERATION OF the City's approval of owners'
development of the property described on Exhibit A without requiring
owners to presently construct the improvements hereinafter described,
the owners covenant and agree as follows:
1. Warranty.of Title. The owners warrant that they are the
owners of the property described on Exhibit A and are authorized to
enter into this Agreement.
2. Acknowledgment of City Authority. Owners acknowledge that
State law and City ordinance provide that the City may require that the
following improvements be designed and constructed as a condition of,
and to mitigate the effects of, the development proposed by the owners
(insert description of specific improvements):
Owners further acknowledge that the consideration for this
Agreement is approval of owners' development by the City without
requiring that such improvements be completed prior to --such approval.
3. Acknowledgment of Special Benefit. Owner acknowledges that
the entire property legally described on Exhibit A, and if the proposed
development is a subdivision or short subdivision, each and every lot
to be created as part of the development of the property legally
described on Exhibit A, would be specially benefitted by the
construction of the improvements specified in paragraph 2 above.
4. Agreement to Participate in or Waive Protest of LID.
A. Petition Method. Owners understand that the formation of
wl .
0 * STREET FILE
local improvement district which includes the property
described on Exhibit A for the purpose of providing the
specified improvements will result in the property being
assessed a proportionate share of the costs of those
improvements. With full understanding of this consequence,
owners agree to sign a petition for the formation of an LID
or ULID for the specified improvements at such time as a
petition is circulated or the City requests the owners to
sign such a petition and the owners hereby agree that the
Mayor of the City may sign the petition for the owners as the
owners' attorney in fact, should the owners fail, refuse or
be unable to do so.
B. Resolution Method - Waiver of Right to Protest.
Owners un erstan tat owners have t e rig -Ft to protest
formation of an LID or ULID to construct the specified
improvements pursuant to RCW 35.43.180. With full
understanding of owners' right to protest and the
consequences of formation of an LID or ULID, owners agree to
participate in any LID or ULID to design or construct the
specified improvements and to waive the right to protest
formation of the same. Owners shall retain the right to
contest the method of calculating any assessment under such
LID or ULID and the amount thereof, and shall further retain
the right to appeal confirmation of the final assessment roll
in.the manner provided by law.
5. Binding Effect - Duration. This Agreement shall be recorded
with the -Snohomish County Auditor, shall constitute a covenant running
with the land described on Exhibit.A, and shall be binding upon the
owners, their heirs, successors in interest and assigns, provided, that
this Agreement shall be valid only for a period of ten (10) years from
the date it is signed by the owners, after which it shall expire and
become null and void.
6. Specific Enforcement. In addition to any other remedy
provided by law or -this Agreement, the terms of this Agreement may be
specifically enforced by the City of Edmonds.
7. Attorney's Fees. In any suit or action brought by the City
of Edmonds to enforce any provision of this Agreement or to redress any
breach, the owners covenant that the City shall be entitled to.
reasonable attorney's fees and costs in addition to any other remedy.
DATED this day of , 1904)
2
STREET FILE
STATE OF WASHINGTON )
)ss:
COUNTY OF SNOHOMISH )
I certify that I know or have satisfactory evidence that
a- signed this instrument and acknowledged it to
be'.(his/her) free and voluntary act for the purposes mentioned in this
:i ns�t�;�meat.
.DATED this � day
of � 19
4 y•
RY PUBLIC
My commission expires: P
STATE OF WASHINGTON )
)ss:
COUNTY OF SNOHOMISH )
I certify that I know or have satisfactory evidence that
signed this instrument, on oath stated that
(he/she) was authorized to execute the instrument
and acknowledged it as the (title) of
(name of party on behalf of whom instrument was executed)
to be the free and voluntary act of such party for the uses and
purposes mentioned in this instrument.
DATED this day of , 198 •
NOTARY PUBLIC
My commission expires:
3
CITY OF EDMUNDS -
,01NISTRUCTION PERMIT APPLICATION
%ME (OR NAME OF BUSINESS)
BJORN THUESEN, INC.
TILING ADDRESS
322 Main Street
rY
TELEPHONE NUMBER
Edmonds, WA 98020
775-1953
ME
Design Consultants - Charles Lee
DRESS
903 loth St.
l
TELEPHONE NUMBER
Mukilteo, WA 98275
745-6569
AE
BJORN THUESEN, INC.
)RESS
322 Main St.
r
TELEPHONE NUMBER
Edmonds, WA 98020
775-1953
TE LICENSE NUMBER
THUESCH161QC
)al Description of Property - include all easements
ow below or attach four copies)
See attached
NEW Ex] RESIDENTIAL PLUMBING
ADD/ALTER 1:1COMMERCIAL
El MECHANICAL
lREPAIR RETAINING WALL
SIGN
❑ EXCAVATE
DEMOLISH OR FILL
❑ FENCE
( _X_FT)'
P.1
REMODEL COMPLIANCESINSP.
swim
POOL
I�
J WOOD NSEROVE/ APT. BLDG
RENEWAL
ER OF STORIES
FNUMBEROF
WGLLINU
1
7E OF WORK TO BE DONE (ATTACH PLOT PLAN)
inble family residence
Ust VWPERMW
ZONE � _ � NUMBER
v7j �
JOB
ADDRESS
1022-3rd Avenue (near Pine St.)
LEGAL DESCRIPTION ECK SUBDIVISION NO. LID NO.
i S-t-1-Q,
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP.
EXISTING v REOUIREDDEDICATION�
PROPOSED_
RIGHT OF WAY CONSTRUCTION PERMIT REQUIRED
STREET USE PERMIT REQUIRED !D2
SEE ENGINEERING MEMO DAT�� �9
?r ARKSAI //A
METE SIZIiBUILDING SUPPLY SIZE FIXT E UNITS
T/ / 11 12—
RE AR
KS,., V
r/f /SIGN AREA ENV. REVIEW ADB NO.
ALLOWED I PROPOSED COMPLETE I EXEMPT
E5
z
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3
VARIANCE OR CU
PLANNINGREVIEW BY
DAT
YARDS
�
FRONT ZSIDE
REMARKS
{ ( HE HT LOT COVERAGE z
C� REAR 25 , % z
g
a
1
CHECKED BY TYPE OF
1
SPECIAL INSPECTOR ,
REQUIRED
❑ YES 0 NO
REMARKS
CHECK FEE
PLAN
BUILDING
PLUMBING
MECHANICAL
Permit covers work to be done on private property ONLY. GRADING/FILL
{y construction on the public domain (curbs, sidewalks,
•eways, marquees, etc.) will require separate permission.
Ile
t Application: 180 Days
t Limit: 1 Year- Provided Work is Started Within 180 Days e4�71'�
�C-
.
GROUP
�_ -Y _S R,
VALUATION
HEIGHT
3 OCCUPANT
LOAD
7y
,57&
L 7
L—el-
pplicant, on behalf of his or her spouse, heirs, assigns and
gssors in interest, agrees to indemnify, defend and hold
less the City of Edmonds, Washington, its officials,
ogees, and agents from any and all claims for damages of
ever nnN vu nr{ainn dir....•.. _. e_�___....____ .� _
PItAnCP REVIEW Cf1rXMIST
ROJ ' NAME:_ V) S F- SEM PR00'DCP ADDRESS: (012- dK' A �•`� � `�
APPLICATION REX:EIPT DATE: -t 61
T
Reviewed by: (initial/date)
ccmmm 15
PIANNING
WrR/SWR I STREET' EaaZNG
FIRE
BUILDING
////// /
////////
iNME FAMILY/MULTIPLE/COMMERCIAL - (Circle One)
TBACRS LI MCKED - Planning
/ / /
/ / / / / /
%/ // % /%% /%/
VARIANCE/SFTAACK ADJ.
/////////
11T11111ITTM1111
////////
//////////
1
—
7T777/7777
MITIONAL USE. PERMIT
1B RECMREM NPS CRBCKID
/
/
/ ////
HER ZONING REQUIR94EM
VIMOOE PAT. FEATURES
LESS SLOPE S VEHICLE ACCESS
`D '
AITQM PLAN (On Site)
//////
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/
7
`REST FILE
�
'.'..11L DESCFtTI'TION VRRIFICATI(N
IT CIATM/DF.DTCATICNS Vl /l'/
//////
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////////
10
/
//// /
—
SEMFNP - 111BLIC/PRIVAIT, tea
11
/
fMATE SEWER COMJF)C. ON IF NO LIDO !/
//
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/////////'
//////%/
12
/ /
/ ///'
—
�T/SUBDMSIOI REQUIRDMM
//////
/////////
//////'/
13
:111T-OF-WAY CONSTRUCTION PERMIT READ.
14
77777
/ /
/
4D REM F17R P1JBI.IC IMPROVIMT M
/////
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///// //
15
[IS CONDITIOpI$ 6 GROUND
%%
/7l
i
['ER FIETI) CHEO(ED
/V////
/////////
/////////
///// //
16
2F.? PAVING REQUTREn
//////
/////////
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17
17777
// /
;_2B AND (MITER REQUTRED
//////
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/// //////
18
77
/ff/%/j%%
.)LWALK RDQUIRED
//////
/////////
/////////
19
//
/�T/7T
/
RB CVP FOR DRIVFWAY REM
//////
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20
/ //
MOP NAME SIGN REQX)
/////////
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21
i(E2 SI(NM READ
//////
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22
DE SEWER AVAILABILITY
//////
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23
[STING WATER'MATN SIZE
/// //
//_///////
6IfC.
24
//
// /
/�
////
///
PER METER SIZE
//////
/////////
25
777
2
EtVI(E LINE SIZE
//////
/� ////
J/y�e
////////
//////////
26
')RANT REQUIRED
/////////
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27
Ilyl/f
)RANT SIZE EXISTING
//////
//////
28
//
)SS. CM4ECTICN INSPECTION RF7QD
//////
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29
ri,1�U.�O
/ /
////l ///
I'ER METER CIMRGE REQO
//////
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30
_
FfTTFIT717
FIRE LINE CHARGE READ - SPRINKLER
/////////
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31
�7
° °
i-
REET CUr
,
32
N DITC14 EXISTING
//////
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33
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34
MEMO TO: Building Division
FROM: Engineering Division
SUBJECT: loLZ 32d S
After review of the subject building permit application, we have the
following comments:
1) Connection to City water system required.
2) Connection to City sanitary sewer system required.
3) Right-of-way permit required for any work.on City property.
4) Driveway slope not to exceed 14%.
5) Back water valve required if downstairs plumbing is below.
6)
7)
elevation ,of upstream manhole.
4
Water and sewer lines to be separated by 10 foot minimum.
Builder/owner responsible for containing all temporary runoff and
erosion on site and may not impact neighboring properties in any
Way.
Construction hours from'7:00 a.m. to 10:00 p.m. on weekdays and
10:00 a.,im. to 6:00 p.m. on weekends and holidays.
re Dept.
UPPER
C ATCH
BASIN DETENTION PIP LXHGTH cONTR01. "TeH
(vGNT)
l I' MIN , 2' MAX COVER
x
OUTLiT
SIX SLOPE+ . ,"
a
K�. i 10 OUT1.VT .
(So PRAM OR .. RUNOFF
SYSTEM CROSS, SECTION
`SEE PAGE 3. FOR OUTLET .CONTROL. DETAIL,
2' • 2' • fo" DSSP' 4 .6 SPA.. m (a►�wara►�)
t . 2' « 9" 06¢P, xij"— GRUSMEfQ 1�CK
FROM �--�
OLrrL ET
CONTROL
RIPRAP OUTLET
Ma►aH 6RAYBL OUTFLOW TitEH1�� MIN 10' LANCa
TOP 4 4" VLF
VaPH TO OR 6&vgl.
f�M
OUTLET
CONTROL
4- PERF PI WITH CAPS
R,U OFF SPREADER TLET
STANDARD 'DRAINAGE PLAN
77
.1-
DETENTION SYSTEM`
PAGE ;I: OF 2'
for 7HNLS�A► Lk5b44-IoM>ES
location,l. 2R 7trrp� awt.1.
x.
plan byphone
L-
date
DESIGN DATA
..
System Imperm Pipe
Pipe
Orifice
Number Area Diem,
Length
Diameter.
NOTES .
1. Call Engineering Division (771.3202),
for prebackfill and final inspecti.pgs.
2. Responsibility for operation and
maintenance of drainage systems on
private property is the responsibility
of the property owner(s). Material
accumulated in the storage pipe must
be flushed out and removed from catch
basins to allow proper operation. The
outlet control orifice must be kept
open at all times.
�AW- 8 —
CITY OF EDMONDS
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August 4, 2004
CITY OF EDMONDS
121 5TH AVENUE NORTH • EDMONDS, WA 98020 • (425) 771-0220 • FAX (425) 771-0221
Website: www.ci.edmondsma.us
DEVELOPMENT SERVICES DEPARTMENT
Planning • Building • Engineering
Katherine Carey_:_ _
�-1022 ';Third Ayenue_South
Edmonds, WA 98020
RE: Hedge Obstruction Along 1022 Third Avenue South
Dear Ms. Carey:
GARY HAAKENSON
MAYOR
Our records indicate that you are the owner of the subject property at 1022 Third Avenue South.
Thank you for cutting the vegetation along your property line. - We appreciate your compliance
in this matter. City of Edmonds staff has revisited the site and determined that the vegetation in
question no longer creates a line -of -sight hazard.
Again, thank you for your prompt response in this matter. Please feel free to call me with any
questions at 425-771-0220, Ext. 1328.
Sincerely,
DARRE C. SMITH, P.E.
Traffic Engineer
DCS/cmc
c: Mike Thies, Code Enforcement Officer
S:\ENGR\Kevin\TRAM01030 3rd Ave. S. North Sight Distance & hedge Letter.doc
• Incorporated August 11, 1890 0
fnc.1890
July 22, 2004
CITY OF EDMONDS
121 5TH AVENUE NORTH • EDMONDS, WA 98020 • (425) 771-0220 • FAX (425) 771-0221
Website: www.ci.edmondsma.us
DEVELOPMENT SERVICES DEPARTMENT
Planning • Building • Engineering
Katherine Carey _ pp
�l 022 Third Avenue South
Edmonds, WA 98020
RE: Hedge Obstruction along 1022 Third Avenue South
Dear Ms. Carey:
GARY HAAKENSON
MAYOR
Our records indicate that you are the owner of the subject property at 1022 Third Avenue South.
We have received a complaint that vegetation along your property line is making it difficult for
drivers to see southbound traffic while looking north as they attempt to enter the roadway from
1030 Third Avenue South. City of Edmonds staff has investigated the matter and determined
that the vegetation in question does, in fact, create a line -of -sight hazard per Edmonds
Community Development Code (ECDC), Street Obstructions, Chapter'9.25 (copy enclosed).
In order to reduce the hazard and enhance public safety, the City of Edmonds is requesting that
you trim this vegetation back so it does not create a line -of -sight hazard. We require you to trim
the pine tree bush next to the mail -boxes along the sidewalk down one foot and to trim the
evergreen tree up two feet. Both vegetations should be trimmed back five feet from the property
line.
Please complete the trimming by August 6, 2004. Your cooperation in bringing your vegetation
into compliance is appreciated.
Please feel free to call me with any questions at 425-771-0220, Ext. 1328.
Sipcerely"-
DARRELL C. SMITH, P.E.
Traffic Engineer
DCS/cmc
Enclosure
c: Mike Thies, Code Enforcement Officer
David K. Gebert, City Engineer
Jim Kammerer, Street Division Manager
S:\ENGR\Kevin\TRAFFIC\1030 3rd Ave. S. North Sight Distance and hedge Letter.doc
Incorporated August 11, 1890
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890 19y
CITY OF EDMONDS
250 - 5th AVE N. • EDMONDS. WA 98020 • (206) 771-3202
COMMUNITY SERVICES:
Public Works • Planning • Parks and Recreation • Engineering
January 4, 1989
Mr. Roger Johnson
1022 - 3rd Ave. S.
Edmonds, WA. 98020
Re: Temporary Telephone Service
1022 3'rd Ave. S. Edmonds
Dear Mr. Johnson:
STREET FILE
LARRY S. NAUGHTEN
MAYOR
PETER E. HAHN
DIRECTOR
The City of Edmonds agrees to allow you temporary telephone service for
a maximum period of forty-five (45) days.
You, in return, agree to provide permanent underground service within
this time period.
Sincerely,
ROBERT J. ALBERTS, P.E.
City Engineer
RJA/sdt
JOHNSON/TXTST530
ACKNOWLEDGEMENT:
Roger J n-son D to
• Incorporcitc l Ari(;usl 11, 1890 Y
Sister Cities International — Hekinan, Japan
CITY OF EDMONDS
IJ NEW
❑ ADDITION
❑ RETIREMENT
STREET FILE ASSET INFORMATION SHEET
ASSET NO.
ADDITION TO ASSET NO.
DESCRIPTION
SERIAL NO.
LOCATION
DEPy. N_
* * PURCHASE ORDER NO.
PURCHASE ORDER DATE
•
COST
* PROJECT NUMBER
PROJECT COMPLETION DATE
COST
B.A.R.S. ACCOUNT NO.
ESTIMATED LIFE
INITIATED BY DATE APPROVED BY
**SUBMIT ASSET INFORMATION SHEET WITH FINAL PAYMENT REQUEST
*SUBMIT ASSET INFORMATION SHEET UPON CLOSE OF PROJECT
ACCOUNTING ONLY
"LJ DEPRECIATE
MONTHLY DEPRECIATION AMOUNT
ANNUAL DEPRECIATION AMOUNT
G.L.
DATE
VERIFIED BY
PROCESSED
BATCH NO. -
by
INIT
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Date:^
Received of:
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$
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Cash
Check
'
Water Meter
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Water Connection
S 1Y q"
Street Cut
PermitlRe air',
'
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Sewer
M
Trunk Char a.
Sewer Connection
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Fence Permit
4 �'
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RIW Invasion
Deposit 620 fund
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Street Restoration
Street Use Permit
,
Bulldin Permit: e
S
Plan Check/Plat Ins action
& Plans Deposit.
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S ecs
Zonin Ap lications
Shoreline Permits
S.E.P.A. Review FDA >�O
✓Recordin Fee
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Permit k
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Time:
Date of Hearing:.
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City of Edmonds. Permit No: 9 9—Z9
RIGHT-OF-WAY CONSTRUCTION PERMIT Issue Date: �rZ�
A. Address or Vicinity of
B. Type of Work (be,,specific):_
0
C. Contractor;
f-f VC: .
C.l, iv d e ce rot
a• .y�4'
Contact:
Mailing Address T6 AAX x/ 44iCG _154 I-//G/l�1 4 • Phone:-"1��_17- 7741" 5 14
State License CC d 6 f Q /# Liability Insurance: Bond: $
D. Building Permit # (if applicable): '' Side Sewer Permit # (if applicable):
"00—
E. ❑ Commercial ❑ Subdivision ;❑ City Project';❑ EUC (PUD, GTE, PS CHAMBER , OVWD) .
❑ Multi -Family ,,JPJ Single Family. ❑ Other ;
INSPECTOR.
F. PAVEMENT: -f frVES ❑ NO G. SIZE OF CUT e�P X 'ge H. Charge: $
CONCRETE CUT: ❑ YES ❑ NO
"APPLICANT TO READ AND SIGN
IDEMNITY: Applicant understands by his/her signature to this application he/she holds the City of Edmonds hdrmless from injuries, 3 q,
damages or claims of any kind or description whatsoever, foreseen or unforeseen, that maybe 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'a
attorney fees by reason of granting this permit'"•
....% r
t
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP. AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING 'THE FINAL
INSPECTION AND ACCEPTANCE OF THE WORKK, 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,safity shall be in accordance with City regulations as required by the City Engineer. Every
flagger'must be tr'ined;ias required by (WAC) 296-155-305 and.;must have certification verifying completion of the
required training in them 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. r
I HAVE READ THE ABOVE STATEMENTS AND UNDERSTAND THE PERMIT REQUIREMENTS AND ACKNOWLEDGE
THAT I MUST MAKE THE PINK COPY OF THE PERMIT AVAILABLE ON SITE AT ALL TIMES FOR INSPECTIONS
Signature: Date:' .�.
( ontractor or Agent)
CALL DIAL-A-DIG,(1-800424-6,5555) PRIOR TO BEGINNING WORK
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