PW Public Works Application Cover Sheet

Public Works Application Cover Sheet
Permit Number:
_________________________________
Assoc. Permits:
_________________________________
PERMIT CENTER
PW
Please read and follow all instructions on your application. Most permits require additional permit information
such as worksheets, certifications, letters, reports or plans. Refer to the applicable supplemental information
forms for required information. Staff will not process incomplete applications. Please print or type legibly.
1
Cross Connection Control
Industrial Waste, Limited Discharge
Storm Drainage
Critical Areas1
Right-of-Way Use2
Tree Removal–Class I (<16,000 sf lot)
Fire Hydrant Inspection
Right-of-Way Vacation
Tree Removal–Class II (>16,000 sf lot)3
Grading
Road Improvement
Water Main/Service
Grease Interceptor
Sanitary Sewer System, Public
Water Meter Installation
House Moving
Sanitary Sewer System, Septic
Water (Hydrant) Use
Industrial Waste Discharge
Sewer Capping
Weekend Work Approval4
Worksheet required.
2
Traffic Control Plan required.
3
Tree Calculation Worksheet required.
4
Letter of request required.
Description of Work:
Site Address/Location:
Subdivision:
Lot No.:
Property Owner Name:
Phone:
Address:
Cell:
City:
State:
Zip:
Fax:
E-Mail:
Contractor Name:
Phone:
Address:
Cell:
City:
State Contractor’s License Number:
State:
Zip:
Fax:
City Business License Number:
Contact Person, if different:
Phone:
E-Mail:
Cell:
Subcontractor Name:
Phone:
State Contractor’s License Number:
City Business License Number:
I/We certify that the information provided in this application, including all submittals and attachments, is true and
correct to the best of my/our knowledge. This application does not constitute approval of permits and/or work to be
performed. For specific fee information, see LMC 3.104 or check the fee schedule available online or at our office.
Signature of Applicant/Agent:
Date:
Signature of Property Owner:
Date:
4114 198TH St SW, Suite 7 | PO Box 5008 | Lynnwood, WA 98046-5008 | Phone: 425-670-5400 | Fax: 425-670-6534 | www.ci.lynnwood.wa.us
Please call 425-670-5201 by 3:00 PM for next business day inspection.
Public Works Application
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SEWER
Side Sewer
Number
New
LF
Repair (LF)
WATER
Private Service
New
Sewer Main
Water Main
Private Sewer (septic)
Water Main Connection
Sewer Lateral
Fire Hydrant
Sewer Cap or septic abandonment
Purity Test
Number
LF
# Dom.
# Irr.
Number
Size
Repair (LF)
Sewer Main Connection
Grease Interceptor
STORM
Industrial Waste Discharge
¾” Meter
Industrial Waste Discharge Limited
1½” Meter (Short, Less Than 25 Ft.)
1½” Meter (Long)
STORM
Number
LF
2” Meter (Short, Less Than 25 Ft.)
Storm Conveyance
2” Meter (Long)
Roof or Foundation drain
Over 2”
Storm Connection
Retention/Detention System
CROSS CONNECTION CONTROL
Backflow Device (SFR or Minor TI)
STREET/RIGHT-OF-WAY
DCVA (Domestic)
LF
Right-of-Way
DCVA (Irrigation)
Anticipated Start Date:
RPBA (Domestic)
Anticipated Finish Date:
RPBA (Irrigation
Number of Days to Complete:
Backflow Device (Comm. or Major TI))
Underground
DCVA (Domestic)
Above Ground (New)
DCVA (Irrigation)
Above Ground (Repair/Replace)
RPBA (Domestic)
Road Improvement Permit
STORM
Total cubic yards of fill and excavation
RPBA (Irrigation
Fill CY
Cut CY
TREE REMOVAL – CLASS I
Number
No. of Existing Trees (> 6” Diameter)
NOTES:
1. The approval of a permit does not in any way replace, modify or waive any requirement for the compliance of the proposal with
other applicable codes, standards, or regulations including, but not necessarily limited to, those of the Community Development,
Fire or Public Works Departments. You are advised to contact these departments concerning such requirements
2. Submittal of this application grants the appropriate city officials the right of entry to the project site during a reasonable hour
and, upon proper identification, to the building, structure and/or premise, which is directly related to this application.
3. It is the responsibility of the owners and applicants to become aware of the requirements of the Lynnwood Municipal Code.
4114 198TH St SW, Suite 7 | PO Box 5008 | Lynnwood, WA 98046-5008 | Phone: 425-670-5400 | Fax: 425-771-6534 | www.ci.lynnwood.wa.us
Please call 425-670-5550 by 3:00 PM for next business day inspection.
Water Main/Service Permit Application
File Name:
____________________________________
For City Use Only
File Number:
____________________________________
Date Stamp
PERMIT CENTER
A Water Main/Service Application shall include the following information, unless specifically waived by the Public
Works Director. Applications shall not be considered complete if any of the required information is missing.
A separate permit application is required for each address.
For Staff Use
ONLY
REQUIRED ITEMS
Verified
Waived
1. Public Works Application Cover Sheet, with original signature(s).
2. Number of Water Main Connections: ______________
3. Number of Purity Tests Required: ______________
4. Length of Water Main to be installed: ______________ LF
5. Length of Private Water Service to be installed: ______________ LF
New
Repair
Check one:
6. Three (3) complete sets of plans, including:
A. Name of the development;
B. Name, address and phone number of property owners;
C. Legal description(s) and parcel number(s);
D. Vicinity map, north arrow, and scale (1”:100’ maximum);
E. The datum and location of the City benchmark used;
F. Site dimensions;
G. 2-foot contours over the site;
H. Location and names of all adjacent public rights-of-way or tracts;
I.
Location and recording number for all easements affecting the proposal;
J.
Proposed water system, including:
(1) Pipe lengths, types, sizes, etc;
(2) Meter locations and details;
(3) Fire hydrant locations and details;
(4) Locations and details for all backflow prevention devices; and
(5) Locations and details of all valves, connections, anchors, etc.
K. Existing and proposed water, stormwater and sanitary systems;
L. The location of any existing or proposed structures or improvements and the setbacks
thereto; and
M. First floor elevations of all existing and proposed structures.
7. All plans shall be prepared, wet-stamped and signed by a Washington State-licensed
engineer.
8. A list of all other required permits and dates applied for.
FEES
See LMC 3.104 or contact our office for current fee information.
NOTES
1. The approval of a Water Main/Service Permit does not in any way replace, modify or waive any
4114 198TH St SW, Suite 7 | PO Box 5008 | Lynnwood, WA 98046-5008 | Phone: 425-670-5400 | Fax: 425-670-6534 | www.ci.lynnwood.wa.us
Water Main/Service Permit
-2-
2.
3.
4.
5.
requirement for the compliance of the proposal with other applicable codes, standards, or regulations
including, but not necessarily limited to, those of the Community Development, Fire or Public Works
Departments. You are advised to contact these departments concerning such requirements.
Items with any typewritten information must be 10-point font or larger to ensure legibility of scanned
documents.
An application may be amended only in writing.
Submittal of this application grants the appropriate city officials the right of entry to the project site during
a reasonable hour and, upon proper identification, to the building, structure and/or premise, which is
directly related to this application.
It is the responsibility of the owners, applicants and agents to become aware of the requirements of the
Lynnwood Municipal Code.
It is the responsibility of the applicant to contact the Underground Location Center at 1-800-424-5555 (or dial
811) 48 hours prior to starting work.
I/We certify that the information provided in this application, including all submittals and attachments, is true
and correct to the best of my/our knowledge. This application does not constitute approval of permits and/or
work to be performed. For specific fee information, see LMC 3.104 or check the fee schedule available online
or at our office.
Signature of Applicant/Agent:
Date:
Signature of Property Owner:
Date:
4114 198TH St SW, Suite 7 | PO Box 5008 | Lynnwood, WA 98046-5008 | Phone: 425-670-5400 | Fax: 425-670-6534 | www.ci.lynnwood.wa.us