17501 69TH PL W.PDF111111 lill 11
5325
17501 69TH PL W
CA FILE NO.
Critical Areas Checklist
--------------------------------------------------------------
Site Information (soil s/topography/hydrology/vegetation)
I Site Address/Location:
2. Property Tax Account Number: F7 L�?D 5C3 60b (�6 1
3. Approximate Site Size (acres or square feet): �Pz_-5�
4. Is this site currently developed? yes; —no.
If yes; how is site developed? - eALO�g
5. Describe the general site topography. Check all that apply.
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
I 0-feet over a horizontal distance of 33 to 66-feet).
Steep: grades of greater than 3 0% present on site (a vertical rise of I 0-feet over a
horizontal distance of less than 33-feet).
Other (please describe):
6. Site contains areas of year-round standing water: AJZ!�> _; Approx. Depth:
7. Site contains areas of seasonal standing water: Approx. Depth:
What season(s) of the year? . ��14
8. Site is in the floodway floodplain A,.)'12 of a water course.
9. Site contains a creek or an area where water flows across the grounds surface? Flows are ar-
round? - AJZ2 — Flows are seasonal? AX.) (What time of year? A-W —).
10. Site is primarily: forested meadow shrubs mixed
urban landscaped (lawn,shrubs etc)
11. Obvious wetland is present on site: A10
- ---------------------- -- - ------------------------ For City Staff Use Only ------------- - ---
------------- - ------------------------
ite is Zoned?
I SCS mapped soil type(i)! ..... ...... ..... . . . . . . . . .
1 Weiland inventoryor CA. map indicates wetland present on s . ite?
4. Critical Areas inventory or C.A. map indicates Critical Area on site?
:5. esignated earth subsidence I dsl*de hazard area?
Site within d' an i
;:6. Site designated'oin the Environmenta . I . I . y . S I en . s . itiv . e . Areas . Map? --A
:* D E TER MI N AT I ON
STUDY
W A ......
Reviewed b
CONDITIONAL WAIVER.
.. I—— lllh,�.Pq� _ _ _ _
/ Date
^ca_chk.doc; Rev 10/03/97
City of Edmonds
CRITICAL AREAS CHECKLIST
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 a development
permit 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 sub ect 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).
4
An applicant, or his/her 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 devel'opment
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 assist staff in completing their preliminary
assessment of the site
I have completed the attached Critical Areas Checklist and attest that the answers provided are factual, to the
best of my knowledge (fill out the appropriate column below).
Owner/Applicant:
Name
Street Address
city State Zip
Telephone
Signature
Date
Applicant Representative:
Name
Street Address
city State Zip
_41
Teleiffione
Signature
Date
I
creception\janakaddoc
(over)
V
�t '? '. 1 S()11
December 16, 1999
CITY OF EDMONDS
121 5TH AVENUE NORTH - EDMONDS, WA 98020 - (425) 771-0220 - FAX (425) 771-0221
DEVELOPMENT SERVICES DEPARTMENT
Planning - Building - Engineering
Wayne Abkion
10749 "A" St. So., Suite A
Tacoma, WA 98444
Subject: Determination regarding Critical Areas Checklist # 99-319
BARBARA FAHEY
MAYOR
Dear Applicant:
Enclosed please find a copy of the Critical Areas Checklist you submitted. The "DETERMINATION" reached by the City
is located on the reverse side of the form (bottom of page).
It is very important for you to retain a copy of this Critical Areas Checklist "DETERMINATION" for your records.
..................................... .......
.. . . .... ... .. ...................................
........ ......
....... ..... ::IMP'Oi.RTANT.INF.O.RMATI.ON.:T.O*'BE.NO.TEL)..�.:.'.�..':.�.'**..'�:..:: .. .... .... . . ...... ... ,
...............
.......................... .................... ......... ... ............... ............. .............
PLEASE EXAMINE THIS" DETERMINATION" FOR ADDITIONAL REQUIREMENTS. YOU MAY NEED TO SUBMIT
ADDITIONAL INFORMATION SUCH AS AN ENVIRONMENTAL CHECKLIS OR CRITICAL AREAS STUDY.
..The 'DETERMINATION' for the Critical Areas Checklist you submitted is a site -specific determination not a
project -specific determination.
You must submit a copy of the CRITICAL AREAS CHECKLIST and DETERMINATION WITH ALL 40
PERMIT APPLICATIONS or YOUR APPLICATION WILL NOT BE PROCESSED.
Permit applications include the following:
Building Permits
Conditional Use Permits
Subdivisions
Variances
Applications to the ADB* Land Use Applications
Any other development permit applications.
Enc: Critical Areas Determination
* Architectural Design Board
C:Reception\Jana\CRLTR.doc
Thank you.
Sharla Graham
Planning Secretary
Incorporated AUgLiSt 11, 1890
Sister City - Hekinan, Japan
City of Edmonds
-'RMV CRITICAL AREAS CHECKLIST
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 a development
permit 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 sub ect 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).
An applicant, or his/her representative, must fill out
th� 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 devel'opment
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 infor m-ation (e.g., site plan, topography
map, etc.) or studies in conjunction with this Checklist
to assist staff in completing their preliminary
assessment of the site
I have completed the attached Critical Areas Checklist and attest that the answers provided are factual, to the
best of my knowledge (fill out the appropriate column below).
Owner/Applicant:
V�k
Name
Street Address
city State Zip
Telephone
Signature
Date
Applicant Representative:
Name
_sZ
Street Address
-74
city State Zip
'57
-5 15-"
Televhone z
Signature
Date
crcception\janakaddoc
(over)
CA FILE NO. 1�1�_ 3M
Critical Areas Checklist
--------------------------------------------------------------
Site Information (soil s/topography/hydrology/vegetation)
I . Site Address/Location: 57 Z�,
2. Property Tax Account Number: 5i 31 60b
3. Approximate Site Size (acres or square feet):
4. Is this site currently developed? yes; _ no.
If yes; how is site developed? ?,jze!� rzl�
5. Describe the general site topography. Check all that apply.
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 lds� than 30% (A vertical rise of
I 0-feet over a horizontal distance of 33 to 66-feet).
Steep: grades of greater than 3 0% present on site (a vertical rise of I 0-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: AJZ--)—; Approx. Depth:
What season(s) of the. year? _ �,�14
8. Site is in the floodway floodplain A-V2 — of a water course.
9. Site contains a creek or an area where water flows across the grounds surface? Flows are ear -
round? Flows are seasonal? —A—Z.) (What time of year?
10. Site is primarily: forested meadow ;shrubs mixed
urban landscaped (lawn,shrubs etc)
11. Obvious wetland is present on site:
---------------------------------------------------- For City Staff Use Only ---------------------------------- -------------- — ----
Site is zoned 0->
1 SCS-mappid soil type(s)?.
3. Wetland inventory or C.A. map indicates wetland present on site?
:4. Critical Areas inventory or C.A. map indicates Critical Area on site?
......................
Site within designated earth subsidence landslide hazard area?..—
:6. Site designated on the Environmentally Sensitive Areas ap.
DEMMINATION
^c&_chk.doc; Rev 10/03/97
14'
14'
4? 10.
10
16p,
Ekistk
.? Wood Do
4-169
A
421333'
21'
MID
G
4W.12'
Existing Sorage
403 of
Existing Drive"
45'
Pr�Sunroorn Addition
x 33'-6'
402 of
58.
Beisting "la Famlig Residence
1`145 of lot Floor
1260 of 2nd Floor
2nd Floor Pidge
1-501 614th Plcre West
M.
6- Exioting covered Porch
210 of
Lins
Temporary Bench Mark Elay.
Top of 6over
Elev. 4W.00 bc1th Placc Kest
Tamporaml Bench Mark
APF�=- 51'North of FlropwN LM&
Center of Raod4q
5 1 TE PLAN
5GALE NTS
456.00
4a4DO
necejv
DEC 2 7 1999
DEVEOpM8NT
SERVICES
CITY OF EDMONDS CTR-
Halwj coulca
A 435-10'
B 4335q'
C. 435.12'
17 4335W
Ave. 6rads = 4a5.41'
17,
Actual = 4555q'
Max1mm = 45b.41'
Lot rgawawgis,
3460 of (42.496)
0 Hkjhast point
Lot Area
43W of
Tax PeffY.61 Numberm
513100014516
.z3.5ql Impacybw Swface Galculation
I Ing
Add.s 402 of
E)dstlng Covered Porche 210 of
Existing Wood Dock s 4-16 of
Existing 6craga s 4W of
__rExisting Com. Driver 646 of
_ 4-32DO
PLANNIMr., DATA
DEC 2 7 1999
NAME: DEVELOPMENT SE8VIC
CITY OF EDMON CS CTR.
DS
SITE ADDRESS: DATE -
ZONING: PLAN CHK#:
PROJECT DESCRIPTION:
CORNER LOT (Yes/No) FLAG LOT
____(Yes/No)
SETBACKS:
Required S
Front:_ 7,.6' Left Side:
- Z]2_�Rlght Slde:_I�p Rear:
Actual Setbacks-:
Front ��b Left Slde:-Pb Right Side:- _Rear:__�
Street map checked for addit . lonal setback required? . (Yes/No)
LEGAL NONCONFORMING LAND USE DETERMINATION ISSUED
(Y/N)
LOT COVERAGE:
Maximum Allowed: Actual:--*
�3 �Ia
BUILDING HEIGHT -
Maximum All�owed: Y
Actual Height:
Datum Point:
Datum Elevation:
"�j
A.D.U. CREATED?:
SUBDIVISION:
CRITICAL AREAS #:
SEPA DETERMINATION:
LOT AREA:
OTHER:
-------------
Plan Review
c%fi1=%pc7W"1ududw
APPLICATION
for
The City of EdmondsSTREET FILE SIODE SEWER PERNIFT
NEW CONSTRUCTION &--- REPAIRS
OWNER........ 644'w'--tp . ...........................................
........ lvog!5�� ...............................
ADDRESS 1.7524-1 .............
40
0
1 0 p 0
QVFn
F E B 2 4- 1970
EASEMENT No . ..........................................
CONTRACTOR ..... Sanu)A—p . ............................ PERMIT No.
LEGAL DESCRIPTION: LOT No. ................................. BLOCK No . .............. ...
ON /
,VgF� So, 0,4-- r.,W Ar- j:FfS7- //0
NAMEOF ADDITI ................................................................................................ ...........................
el-�We
Approved:
. .............
.. . ................ . .. .............. ..
DATE...2..-.,2.Y ...... ZQ ......... By ...... ......
CITY� OF EDMONDS
Call PRospect 6-1107 when work
CIVIC CENTER WATER -SEWER DEPARTMENT is ready for -inspection. (No inspee-
tions Saturday, Sunday or holidays.) N2 3579
SIDE SEWER PERMIT
ADDRESS................ 6.9th ... Place ... we.st ............................................................................................................................
OWNER ................... E.dwair.d --- C.orin.e.r ........................................ CONTRACTOR ........... W.�.s te.rn .... Sew.e.r ...................................
.. ....... .. .. .. .... .. .. .. .. ....... .... ....... .. ..
Perinission is granted ...... KIP)�Rq4rY --- 2A ......... 19.7Q.., for ........................ days to REPAIR or CONNECT a side sewer
"rith City Sewers in accordance With application on file and governing ordinances. ,
ATTENTION IS CALLED TO THE FOLLOWING:
NOTE No. 1—The owners of the property may obtain a permit to construct sewer inside property line. A licensed Side Sewer Contractor must
be employed to construct side sewer In street axea. Do not cover any portion of sewer before it has been Inspected.
E No. 2�Obtaln full Information regaxding Ordinance 11.16.030 and Regulations governing side sewers when you get permit.
"i,c)TE No. 3—Top of side sewer must have at least 30 inches coverage at property line and 12 Inches Inside property line; minimum grade of 2%.
No bends in grade sharper than 'A will be permitted.
NOTE No. 4—Trenches in street must be water settled and surface of street restored to original condition. Contractors shall be responsible for
failure due to Improper work whIch may develop within one year of completion.
NOTE No. 6—It is unlawful to alter or do any other work than is provided for In the permit, or to do any work on the main sewer or its appur-
tenances except to insert the pipe into the wye.
01
STREET FILE
CITY OF EDMONDS
DEPARTMENT OF PUBLIC WORKS
250 Fifth Avenue North, Edmonds, Washington
SEPTIC TANK INSTALLATION PLAN
(Submit in Triplicate)
Aweir-1
ADDRESS OF PROPERTY ..... . ....... Lot No ...... 46 ......... Permit No. "..
Owner_ ... ..... ..................................................... ------ Address ... .................... --------------- ---------- ........ ...... Phone ........................
Builder ------
Address.,101)(. _,46; 11W,410%ef Phon",i(I 7
.............. ........ Phone.—P 2e:1-
Designer ......
Installer.;��
.......................
I hereby certify the accompanying drawing is an accurate representation of the system installed at the listed
address. I also certify all recommendations and restrictions (concerning plumbing stub elevations, maintenance of
giA6Pw,, fills, surface drains, etc.) listed by me on my sewage disposal system permit application dated.../A�0-4,7'
................. have been complied with.
................. ................................
-'�34 -- --- ---- - ...
Signature of Designer
TO BE FILLED IN BY CITY ENGINEER ONLY
Accepted. .. ............. -------------- .. .......... Date ...
Not Accepted ............. ...... ...... Date
Signatureof Sanitarian.. ----------- ......................................... ...........................
Remarks: ........ Approved -.per ... designer's..certification .......................................................... ............. ...............
INSTRUCTIONS: Use the reverse side of this form for the drawing. Use a scale which will permit the greatest
detail and still contain the entire site on one page.
ATTENTION HOME OWNER:
Your septic tank has limitations! It was designed and installed to care for an average -size family. Over-
Joadin,g the septic tank or disturbance of the drain -field may seriously impair satisfactory operation. Points to
remember:
1. Have your tank checked periodically to see if pumping is necessary (2V2-3 years).
2. Do not channel ground water, surface water, footing drains or downspouts into the tank or drainfield.
3. Do not excavate, fill, place a structure, driveway or.patio in, on, or ove'r the drainfield.
4. Limit toilet fixture disposal to sanitary wastes and toilet tissue.
5. Detergents and bleaches used in normal household quantities will not harin the action of the septic tank and,�
disposal field.
12
** 00
,Rv.eex,e 8
Is
"VIP
7A&�
I-OX A5�eW
.1,or r��
/ - a 57 �� -
�A
I
oo
40
a
�A
SEWAGE* DISPOSAL RMIT
.N �an .......... gals. ...........
Sc -T! No.
ptic, .-CIT MONDS
Y 0 F E'D
Department of Publie-Works
ft.
Disp.,Field ........ :_.;?Mn
Othe r*:.,,...
....................................
.......... z
.... . ......... ... ... is.hereby authori ed tor.insta
Na- LIAM ........... ......
--------- ----------------
repair sewage disposal -.system. a
acia - ip-st ....... ...........
.... ........ .........................
........... - ------ ............. .................
.............
Date issued on.. ....... :sLjitembb .. ..... .............
Permit expires, one year -from date issue.
D SIGNER OR SANITARIAN
0 NOT COVER BEFORE APPROVED BY DE
_C I ity.!,
h system was i stalled under my supervision and control and complies with all provisions oi:the
n
J, ereby.g.ertify this
Pi -Edrflonds Resolutions.
Signature of Installer... ........................................................ �. Date ................ 7 . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . .
By.: ..................... .................... ------------------------ .............. .
Disapproved F� Date ................................................................
-A prove,'
P
....................... ...................
maxki:� ............. ...................................................... . ------------------ ------ -------------------------------
. . . .............
te
........ ba ...... tL; J. —.6 -------------------- - --
'SANITARIAN OR -I)ESIGNER ........
uo u s p, ace.: oft the job� ti 1i en �'compleied.'
p- rinit 'li il I be' .1 inipecii�� has. e
-s posted."in a reasoii,�_esns, ic . un y
T�is y
tll6h�_41i, (541146 _E .6
N S)1&j&.Ct, 'tq .,it.v_
'7117/6
CITY OF EDMONDS
DEPARTMENT OF PUBLIC WORKS
250 Fifth Avenue North, Edmonds, Washington
APPLICATION FOR A SEWAGE DISPOSAL SYSTEM PERMIT
(Submit 3 Copies)
0000�"
Permit to be issued to: ................................ <7--flo ----- 9:5ro'eO.900
For installation at: (street address) ----------- 176-V A .......... ....................................... ........................
-V- .0
're Ogg eemro ..000-e' ";6
Addition or Subdivision.&, .0-0-re. 4- XVIW� Lot ................ Block ................
Type of Building: New.X ...... Existing ------ .... Single family residenceX4f:Y. Number of bedrooms.,--?.....-. ..............
Other: (specify type or use)
Builder ........ 5;;Zge�.V .. .................... ..... Address.
Designer .... _A .0 .............................. Address ---
Soil Log Hole No. 1 ----- - ov "';;p .. oogA
--------------------------------------------- ............. ......... ....................... ............. ..............................................
Soil Log Hole No.
4.�-'eew ............
............ I.O.F4-.000f.. _4.r�CoW_Al ......
-OV/ev* Z . . ........ ...... ...... ...................................................
Elevation of Water Table, if encountered. (Distance from ground surface) _.A.10A1467. ... ......... ..............................
Corre ctions to control surface water if needed... .0. 10.w�e .. 7 ..... If '��.40_eex ..............
0�
......... I .. ...... ....... .................
Specify if any removing or grading of topsoil in field area ... 'X_
&W— .. � . . .. .................................. ...............
..........................................................................................................................................................................................................
Percolation:
Test Hole No. I
—Average
Rate ... 4O.'s ----
#I
41t'7
(Fall in tyiintites/inch-bottom 6" test hole)
Test Hole No. 2—Average
Rate//4.Z ....
........
......... (Fall in iiiinutes/inch-bottom 6" test hole)
Test Hole No. 3—Average
Rate__4�.3 ....
4F.e�? ... ....
..... _ .... (Fall in minutes/inch-bottom 6" test hole)
Average percolation rate on which to base drain field design
Date Taken _.7!:f;!. _4T"'
Septic tank requirements based on present rules
and regulations:
Septic Tank Size. ........
1P .......
gallons.
Amount of Square Feet of Disnosal Field. .... ..... .....
Signature — Designer ............... ------------- -------------- - ---- - Date._ ...............
DO NOT WRITE BELOW THIS LINE (To be completed by Issuing Agency)
Permit issued (date) ....... ................................ Permit Number....,�.�.oR .............................
Remarks: ...... ..
. ... . . . .................. -------------_---- ----------- 7 .......
'A'6 00
Av Ap
T jF
-19
If
.0
A i
Z-2
ol
kn
2 r'
, 02
0 7- /alz /P1V
9 t4
e,,07;-,O Al
7301 179th S. W.
EDNIONM'WASMINGTOM.
PERCdLATION TEST
. pq-01
F- 14 4 79 4
DESCRIPTION
The North 85 feet of the South 303 feet of the East. i10 6et.,6f the
West 280 feet of Lot 145 MEADOWDALF BEACH, according,to pIgmtfiereof
recorded in volume 5 of plats, page 38, records of Snohomish Countys
Washington;
T0GFT11rR WITH easement:
An easement for ingress, egress and utilities over and across that por-
tion of the East 135 feet of *�-Iest 280 feet of the South 413'"-feet of-�Lot
145 MFADOWDALE BEACH, according to plat thereof recorded in volume 5 of
plats, page 38, record3 of Sno�ic,,rnis'h County* Washington, thereof: Begin-
ning at the Southwest corner of said Lot 145; thence East along South
line of said Lot 145, a distance of 170 feet to the point of begin-
ning; thence North 1046110" West parallel to the West line of said
lot 14S. a distance of 313 feet to the point of tangency of a curve
to the right having a radius of 25 feet; thence along said curve
to the right thru a central angle of 90', an arc distance.of 39.27
feet; thence North 10461100" West 18 feet; thence angle left 900
to become tangent to a curve to the right having a radius of 25 feet;
thence along said curve to the right thru a central angle of 900, an
arc distance of 39.27 feet; thence North 1046110" West 32 feet;
thence West parallel to the South line of said Lot 145, a distance
of 25 feet; thence South 1046110" East 413 feet to South line of
said Lot 145; thence East along said South line 25 feet to the point
of beginning.
bATE
RECEIVED
d-
PERMIT EXPII
CITY OF EDMONDS
USE PERMIT.
ZONE
NUMBER
CONSTRUCTION PERMIT APPLICATION
JOB SUITE/APT#
ADDRESS
V-A-
OWNER NAME/NAME OF BUSINESS
A)
PLAT NAME/8UBD1VISION NO.
LOT NO.
LID NO.
I
LIDFEE$
Cc
w
MAILING WbRESS
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Apptwed
RW Permit Required W!"
z
0
EXISTING — PROPOSED
street Use Perrnit'Req'd40
lZectic Required,
za440/
CITY ZIP
TELEPHONE
REQUIRED DEDICATION— FT —
Sidmalk'4equiredf .0 0
Underground it/ 'w
�7?17
Wiring required 0
NAME
METER SIZE
LINE SIZE
NO. OF FIXTURE
PRV REQUIRED
YES 0 NO 0
z
ju
ADDRESS
REMARKS
z
0
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
z
/c,
CITY
TE�,EPHONE
1.7
NAME
ENGINEERING REVIEWEDIAT
ADDRESS
x
FIRE REVIEWED BY DATE
tu
CITY ZIP
C.
X�
TELEPHONE,,,.
Pr "J"_ ��t �,7
z
OU
!K
U.
74 .124
J / -
_ .9�, _0
VARIANCE OR CU
SHORELINE OR ADB#
INSPECTION
BOND
XQSTFD
I
STATE LICENSE NUMBER EXPIRATION DATE
CHPC Y
i /. /_, ,
41 —
, EP
0 YES 0 NO
(
SERA REVIEW
I EXEMPT
....
SIGN AREA
ALLOWED PROPOSED
HEIGHT
PR
ALLOWED OPOSED
-j
PROPEFV TAX ACCOUNT PARQELYO.
Ij
_j
tf
NEW RESIDENTIAL PLUMBING MECH
LOT COVERAGE
ALLOW)ED PROPOSED
REQUIRED SETBACKS (FT.)
FRONT SIDE REAR
PROPOSED SETBACKS (FT.)
FRONT URSIDE REAR
COMPLIANCE OR
ADDITION 0 COMMERCIAL
0
1P
I A
z
7
CHANGE OF USE
REMODEL C3 APARTMENT C:] SIGN
z
PARKING
REG'?, ff9.QyIDED
��T AREA
N IN"EVIEWED BY �'DATE
t
t,
4117f111'N--,;;`) I I'VrN
GRADING
[D FENCE
REPAIR CYDS FT)
REMARKS " , , / .11
DEMOLISH E] TANK C3 OTHER
z
Ei GARAGE RETA'NING WALL RENEWAL
CARPORT R CKERY
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
CHECKED BY
TYPq OF COqSTRUCTION
CORIE OCCUPANT�l
GROUP
.
NUMBER ., )
OF
NUMBER OF
DWELLING
CRITICAL
AREAS
Lu
SPECIAL INSPECTOR
OCCUPAN
'0
STORIES el - -7
UNITS
NUMBER
JAREA
REQUIRED YES
DESCRIBE WORK TO BE DONE
REMARKS
z
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D
5
'A
P Lgtol_,
VALUATION
FEE
PLAN CHECK FEE
HEAT SOU E GLAZING % LOT SLOPE %
BUILDING
PLAN CHECK NO: VESTED DATE
PLUMBING
o,
MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
1,_ BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
2
GRADING/FILL
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
STATE SURCHARGE
cc PER1011TAPPLICATION: 180 DAYS
LU
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENG. REVIEW FEES
SEE BACK OF PINK'PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIR
U) S, ASSIGNS AND SUCCESORS
ENG. INSPECTION FEE
Lu IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
i
LANDSCAPING
2 EDMONDS. WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
INSPECTION FEE
cc ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
RECEIPT
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANYWAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
RECEIPT ij!"
TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT, AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
This application is not a permit until signed by the
CALL
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
Building Official or his/her Deputy: and Fees are paid. and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION �eceipt is acknowledged in space provided.
WORKMEN'S COMPENSATION,rINSURANC5 AND RCW 18.27.
OFFlq[A,�S SIGNIATURE DATE
(OWNER OR'AGENT [DATE SIGNED
SIGN�T�
(425) ,e
1./12
771-0220
RELF�SED BY DATE
ATTENT16N
EXT 333
f
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL FILE YELLOW INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
RIGA
FAX PINK -OWNER GOLD -ASSESSOR