1044 C AVE.PDF11111111111111
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1044 C AVE
ADDRESS:
TAX ACCOUNT/PARCEL NUMBER b�Q 4O D �Db�k�O
BUILDING PERMIT (NEW STRUCTURE):
COVENANTS (RECORDED)
CRITICAL AREAS: DETERMINATION: ❑ Conditional Waiver ❑ Study Required ❑ Waiver
DISCRETIONARY PERMIT #'S:
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
PERMITS (OTHER):
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED:
SEWER LID FEE
SHORT PLAT FILE: 5 ' &10 - o LOT:
SIDE SEWER AS BUILT DA'
SIDE SEWER PERMITS) #:
GEOTECH REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
WATER METER TAP CARD DATED: I I
LID #:
BLOCK:
LATEMP\DSTs\Forms\Street File Checklist.doc
APPLICATION
for
The City of Edmonds SEDE SEWER PERMIT
NEW CONSTRUCTION Ej REPAIRS E] EASEMENT No ...........................................
107 07500
OWNER......... Dona-ld-C.-M.1by. ............................................................. CONTRACTOR ................. ................................................................................ PERMIT No . ......................
ADDRESS ...... 1044--C ------ Street --------------------------------------------------------------- LEGAL DESCRIPTION: LOT No . .............................................. BLOCK No . ............................................
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NAMEOF ADDITION ..........................................................................
DYE TESTED ON SEWER
JULY, 1972
Approved:
DATE................................................ By ......................................................................
EMj,O PAfD.OQT -1
• . � ..:District _ u;' - _._
- Cit} of Edmonds ---Water Department
1 TAP CARD
Date
Flo No. ......
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-=M `Tap z
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Size/ Size
Mfgrs No. le . ......
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. .No:._.....Lot No ._ ........ . ..
Add:...........................................................
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Service Location J �'�
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.Meter Location.
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Pressure lbs. T,est:.:..»..
;Serid'-Bills to
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Date of Work :`Z
7y
Foreman
..................................... .................. Guar. Voucher No....: ....... ..$.................................... »....,
Remarks: :....u.. ...».... .............
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OUTGOINGIndex--L....:Re......RouteBk.........Stencil:.....Card........
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CIT.Y b' EDMOND ' * r n O O JT e if No.
COMMUNITY SERVICES DEPARTMENT STREET FILE Issue Date 10s7- ke
RIGHT-OF-WAY CONSTRUCTION PERMIT
A. • Owner: Washinctton Natural Gas Co B. • Contractor
8N' 156 AV NE
Mailing Address
Bellevue, WA 98007
City State Zip
Same
Name
Mailing Address
City State Zip
447-0700
State License Number Telephone Number
• Address or Vicinity of Construction: 10..4.4 C AV
Type of Work to be Done- Nevi' 'a �6rVice installation /lg
1 "� i r •f �' ��z
Work in Connection With: ❑ Sub or Plat ❑ Single Family ❑ City Projects
Z ElCommercial ❑ Multifamily? Utility
1 Q Pavement Cut: ❑ Y ❑ N
1U
1 a APPLICANT TO READ AND SIGN
a
1 Q INDEMNITY: Applicant understands and by his signature to this application, agrees to hold the City of Edmonds
1 >, harmless from any injuries, damages, or claims of any kind or description whatsoever, forseen or unforseen, that may
1 A be made against the City of Edmonds, or any of its departments or employees, including or not limited to the defense
1 of any legal proceedings including defense costs, court costs, and attorney fees by reason of granting this permit.
1 THE CONTRACTOR IS •RESPONSIBLE FOR WORKMANSHIP AND -MATERIALS- FOR A. PERIOD OF ONE
--YE;#R=,FOLLOW-I'NEr`FIDE'FI°NAL-INSPECTION_ANDrACCEPTAN tV F';T Ii '1�VORK''"
1 U Funds held from the Security Deposit (estimated restoration fee) will be held until the final street patch is completed
1 by City forces, at which time adebit or credit will be processed for issuance to the applicant.
• A 24 hour notice is required for inspection; Please call Public Works: 771-3202
1 • Work is to be inspected during progress and at completion.
1 • Restoration to be in accordance with City Code.
• Street to be kept clean at all times.
1 • Traffic Control to be in accordance with City regulations.
1 • All street -cut ditches must be patched with asphalt or City approved material prior to end of working day;
1 no exceptions.
I understand the above and that this perm' must be available at the job site for inspection purposes at all times.
Signature: Date: 10 / 3/ 8 8
Owner or Contractor
This Permit Must Be Posted at the Job Site For Inspection Purposes
Call DIAL -DIG Prior To Beginning Work
ISSUED BY: C-m. D� PERMIT FEE: �, O- DD
Time Authorized: Void after days. Security Deposit: /
Special Conditions: I i �' Receipt N&
Amendments:
Fund III
Street Cut Dimensions:
X =
NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE
Eng. Div. July'1985
.t ,
FIELD INSPECTION, S "un I I - Route copy to Street Dept.)
Comments:
Diagram:
vy
CONTRACTOR CALLED FOR INSPECTION ❑ YES ❑ NO
Partial Work Inspection by P. W.:
Work Disapproved. By: Date:
FINAL APPROVAL BY: Date:
GIIS. illy. JUI)•
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