17915 73RD AVE W.PDF111111111111
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17915 73RD AVE W
ADDRESS:
TAX ACCOUNT/PARCEL NLJM13ER:
BUILDING PERMIT (NEW
COVENANTS (RECORDEE
CRITICAL AREAS: DETERMINATION: El Conditional Waiver F] Study Required J240aiver
DISCRETIONARY PERMIT
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
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0711M.0i'mm
PLANNING DATA CHECKLIST DATED: 1A // 71d /
SCALED PLOT PLAN DATED:
SEWER LID FEE $: LID
SHORT PLAT FILE: LOT: . BLOCK:
SIDE SEWER AS BUILT DATED:
SIDE SEWER PERMIT(S) #:
SOILS REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
117 A 'MUD WAUrUD 'r AD f1 A DT'% TIAMPTI.
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ADUL____TF1/AM1LYnu0 ME LICENSE
License Number: 532000
Pursuant to -the laws of the State of Washington and the Minimum Licensing Requirements
of the Department of Social and Health Services a license is hereby granted to
TATIANA CEMTAN and NICU VAS.ELE CIMPAN
to conduct and maintain at 17915 73RD AVE W
city of EDMONDS, Zip Code 98026 County of SNOHOMISH State of Washington
an Adult Family Home for the care and supervision of adults as follows:
24-hour care for no more than' 6 adults
This licensoe shal . I be M" fo= from the 31st of July, 2000 subject to suspension or revocation for due cause.
This bome has a special designation to provide iiervice to persons with: Dementia Mental Ulness
Conditions on License, if any:
Licensing Authority
?VffFU_U
NOTE: The department rene%val of a license does not pTeclude. the department from bLking any action under WAC 388-76-70.5, based on inspection.
This license is not transferaMe, 96d is valid onV for -use by the corporation, pastner-Aip or individua)(s) towliom It is Issued and at the location above des-c"bed.
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PLANNING DATA
SITE ADDI
PROJECT
REDUCED SITE PLAN PROVIDED?(J�AQNo)
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FLAG LOT: ff -0411Q-05
-Z5 CRITICAL AREAS DETERMINATIONM
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SEPA DETERMINATION:
JFee
13 Checklist
L3APO list w/ notarized form
U (Needed for 500 cubic.yards of grading, Shoreline Area- site within 200 ft. of Puget Sound or Lake Ballinger)
,�94xempt
SETBACKS:
Required Setbacks: , f
Street: 2:!E Left Side: Right Side: -7. Rear: I
Actual Setbacks: ^_,o /
Street: -Left Side: Right Side: Rear:
Street m5p chocked for additional setback required? (Yes No / DNA)
DETACHW STRUCTURES:
BAY WINDO!� /.PROJECTING MODULATION:
STAIRS / DECKS:
PARKING: Required: ::2-- Actual:_��
LOT AREA: 40 10 0&%pt- Afrr-wx I I ;e-
LOT COVERAGE;, �::W . - - -,,
BUILDING HEIGHT: ",177- /Afo 60+Atferp- -73> EXIS-77Ag�,
Datum Point: Datum Elevation:
Maximum Allowed: Actual Height:-
A.D.U. CREATED??(6QYes)
SUBDIVISION:
LEGAL NONCONFORMING LAND USE DETERMINATION ISSUED: (Yes / No
OTHER: A - t.* � el�—�
Plan Review
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OfFence must be located on private property.
@Property owner responsible for determining
property lines.
eFence shall not enclose or prevent access to any
City maintained utilities.
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RECEIVED
STREET FILESEP - 3 2003
DEVELOPMENT SERVICES CTR.
CITY OF EDMONDS
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RECEIVED
: - - - - -'-SEP - 3 2003
DEVELOPMENT SERVICES CTR.
CITY OF EDMONDS
?A-R-CCL #:--47,57,6W0
43oa
Nicu & Tatiana Cimpan
17915 73rd Ave. W.
Edmonds, WA 98026
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City of Edmonds
Development Services Department
Planning Division
Phone: 425.771.0220
4c. I %9Z 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. Ile 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:
City Receipt#:_ U
Critical Areas File #:
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 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 to file "plication on the behalf of the owner as listed below.
AI
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 publi offilcials and the staff of the City of Edmonds to enter the subject property for the
purposes of inspection and postin tt dant to this application.
SIGNATURE OF OWNER—, DATEvAsAh-&.
Owner/Applicant: - I
,</ I �Ij V, C i M PAQ
Name r 4.
1111 -T 3
Street Address
Vowls— L�J V90 Z
city State zip
Telephone:
Email address (optional):
Applicant Representative:
Name
Street Address
City State Z*
IP
Telephone: 0
Email Address (optional):
Critical Areas Check] ist.doc/4.22.2003
Critical Areas Checklijp CA File No: 03 -1 7A
Site Information (soils/ topography/ hydrology/vegetation)
0 1. Site Address/Location: Gxu"3' 73, Avc-, W. F-dw&cJ-,- tYl-q. j?,Pc)eg-
2. Property Tax Account Number: 4 ;1 37 AW 0 0
3. Approximate Site Size (acres or square feet): 670" S
4.. Is this site currentlydeveloped? -�-Tes; no.
If yes; how is site developed?
5. Describe the general site topography. -Check all that apply.
Flat le'ss than 5-feet elevation change over entire site.
91
7.
8.
9.
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):
Site contains areas of year-round standing water: ,474 Approx. Depth:
Site contains areas of seasonal standing water: Approx. Depth:
What season(s) of the year?
Site is in the floodway floodplain
of a water course.
Site con a creek or an area where water flows across the grounds surface? Flows are year-round?
& A — Flows are seasonal? (What time of year?
10. Site is primarily: foresLed---_----,__ meadow shrubs mixed
urban landscaped (lawn, shrubs -et -ET
11. Obvious wetland is present on site:
For City Staff Use Only
1. Plan Check Number, if applicable?
2. Site is Zoned? P-'B- 9)
3. SCS mapped soil type(s)? A�A 4A 23
n 4Ar); 1 -4�-��
4. Critical Areas inventory or C.A. map indicates Critical Area on site? t-�o
5. Site within designated earth subsidence landslide hazard area? kDot- 8 n A A—
r 0 CL
DETERMINATION
STUDY REQUIRED WAIVER
Reviewed br. C-*nl P11- Datp! n I I- 5z�
Critical Areas ChecklisLdoc/4.21.2003
OF EDMONDS
USE
ZONE
PERMIT
CITY
RS
- 8, NUMBER
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS—ro4-r /�V/09 r, 1/.f
C
JOB
DDRESS
E/AP Ir
Ale-
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LEGAL DESCRIP
TION CHECKISLIGOIV1110H NO LID NO
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP. TESCP APP—ed a
ZIP NELE—ONE NUAI R
RW Permit Re,,,keo 0
EXISTING
— REQUIRED DEDICATION Street LIM Permit R.Q d 0
IPA j�j nAIA S a (412:�)-73�
PROPOSED
Insmtion Requi—
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Sid-11, R.Q.i,W 0
SAM
METER SIZE
I LINE SIZE I NO. OF FIXTURES IRV REQUIRED
ADDRESS
YES C3 No 0
CITY ZIP
TELEPHONE NUMBER
6
IRE MEMO DATED REVIEWED BY
STATE LICENSE NUMBER EXPIRATION DATE
VARIANCE OR CU
ADS
SHORELINE 0
Legal Description of Properly - include all easements
SERA REVIEW
COMPLETE EXEMPI
SIGN AREA
LLOW7
ALLOWED PROPOSED
HEIGHT
ALLLO1 1 OPOSED
0
EX I
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED S T SACKS (FT)
(I, I
FRONT SIDE REAR
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FRONT URSIDE REAR
Property
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TeX A=u't 4737.
Pa irool No.
LOT AR07—
9
HEW RESIDENTIAL ILU....ECH
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COMPLIANCEOR
ADDITION COMMERCIAL CHANGE OF USE
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ElREMODEL E] APT. BLDG. SIGN
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REPAIR
DEMOLISH [:) WOOOSTOVE SWIM POOL
INSERT HOT TUB/SPA
NECKED BY
TYPE OF
TYPE OF ONSTRUCTION
A,`HeaWxA4-4
I CODE—
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OCCUPANT
PECiAL INSPECTTO�ARKA
EOUIRED
OCCUPANT
E] GARAGE rl RETAINING WALLI
LOAD
Z
CARPORT Il ROCKERY ML
E-A. S
(TYPE OF
_YSE. Bubw OR,ACTIVITY) EXPLAIN:
PROGRESS INSPECTIONS PER UBC 108
NUMUER
NUMBER
CRITI
ITI AL
OF
STORIES yZ�
DWELLING
UNITS
AREAS
NUMBER
DESCRIBE WORK TO BE DONE (ATTACH PLOT PLAN)
#
FINAL INSPECTION REQUIRED
VALUATION
l,7L_
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PLAN CHECK FEE
eii�ll
HEAT SOURCE:
_V
7/
BUILDING
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PLUMBING
Plan Check No.
MECHANICAL
This Permit covers work to be done on p Ivale property ONLY.
GRADINGIFILL
Any Construction on the Public domair (curbs, Sidewalks,
driveways, Marquees, ( ite Permission.
STATE SURCHARGE
Permit Application: 180 Days
Permit Limit: I Year - Provided Work IIII Started Within 180 bayS '
STORM DRAINAGE FEE
"Applicant, on behalf of his or her spouse, heirs, assigns and
ENG. INSPECTION FEE
successors in in!erest, agrees to indeMn ly, de fend and hold
harmless I he City of Edmonds, Washington, its officials.
employees, and agents from any and all claims for damages of
whatever nature, arising directly or Indirectly from the Issuance
of this permit. Issuance of this permit shall not be deemed to
PLAN CHECK DEPOSIT
modify, waive or reduce any requirement of any city a dinanc
nor limit I� any way the City's ability to enforce any ordi Tance
provision.
TOTAL AMOUNT DUE
I"
I hereby ac nowledgo that I have read this application; that the
Information given is correct; and that I am the owner, or the duly
authorized agent of the owner. I agree to comply with
ATTENTION
APPLICATION APPROVAL
city and
3 late laws regulat I ng construction; and In doing the work authoriz.
ed thereby, no person will be employed In violation the
THIS PERMIT
AUTHORIZES
This application is not a permit Until
of Labor
Cod 0 of the State of Washington relating to Workman's Compensa-
ion
ONLY THE
WORK NOTED
signed by the Building Official or his/her
Deputy; and fees are paid, and receipt is
Insurance aria RCW 18.27.
acknowledged in space provided.
TI
IG.-- (OWNER OR AG DATE
'�72
j/it I
DINSPECTION
' PARTMENT
CITY OF
OFFICIALS SIGNATURE DATE
EDMONDS
4k4z) tz;7-off)
ATTENTION
CALL FOR
ON- DATE
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
INSPECTION
UNTIL A F:NAL INSPECTION HAS BEEN MADE AND APPROVAL OR
A CERTIF CATE OF
771-0220
ORIGINAL File
OCCUPANCY HAS BEEN GRANTED. UBC
— YELLOW — inspector
SECTION 109
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License Number: 532000
Pursuant to the laws of the� State of Washington and the Minimum Licensing Requirements
of the Department of Social and Health Senrices, a license is hereby granted to
TAT1ANA CIWAN and NICU VASULE Cl[MPAN
to conduct and maintain at 17915 73RD AVE W
city of EDMONDS, zip Code 98026 County of SNOHOMISH State of Washington
an Adult Family Home for the care and supeMsion of adults as follows:
24-hour care for no more than' 6 adults
This license shall be in force from the 31st of July, 2000'stibject to suspension or revocation for due cause -
This home has a special designation to provide service to persons with: Dementia Mentalffiness
Conditions on License, if any:
Liomsing-Andiority
NOTE: The department rene%val of a Howse does not preclude Lbe department from bddng any action under WAC 388-76-70.5, based on inspection.
This license is not trausferab)e, a6d is valid onV for use by the corporation, partacnhiper ifidividual' to w1iom it Iz Issmed and at the lomflon above de-nn
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CITY OF EDMONDS
121 5TH AVENUE NORTH - EDMONDS, WA 98020 - (425) 771-0220 - FAX (425) 771-0221
DEVELOPMENT SERVICES DEPARTMENT
Planning - Building - Engineering
September 8, 2000
Tatiand Cimpan
Olympic View Adult Family Home
17915 73d Avenue West
Edmonds, Washington 98026
RE: Adult Family Home @ 17915 73d Avenue West
GARY HAAKENSON
MAYOR
The purpose of this letter is to inform you that it has come to the attention of the Building
Division that your adult family home has not met all local provisions for permits and.
business licensing requirements as mandated by WAC 388-76-190#1. Adult family
homes are still a fairly new use in our State and it has taken several years for local
jurisdictions to develop a working relationship with DSHS to coordinate regulations.
Also, the state law governing adult family homes is specific in that it is the applicants'
responsibility to check with the City to ensure all local codes are met, but our research
indicates this is typically being overlooked by the adult family home owner(s).
Enclosed is the City handout for Adult Family Homes that has been sent to all licensed
care facilities in Edmonds City limits. It is our intention to gain code compliance from all
the licensed homes so that local mandates are enforced equally. Please review the
enclosed materials and contact me at your earliest convenience to setup a meeting so that
we can discuss how your adult family home can meet our City codes. I can be reached at
425-771-0220 if you have any questions. If you find that the handout adequately answers
your questions and a meeting is not necessary, please feel 6ee to apply for the required
permit and license at City Hall and the Building Division between the weekday office
hours of 8:00am to 5:00pm.
Thank you,
Jeannine L. Graf
Building Official
Incorporated August 11, 1890
Sister City - Hekinan, Japan
0 0
RE TURN ADDRESS: CONFORMED COPY
City of Edmonds, City Clerk 200010020237
121 5th Avenue North 10/02/2000 11:41 AM Snohomish
Edmonds, WA 98020 p.0003 RECORDED County
NOTICE OF LIMITATION AND COVENANT
ADULT FAMILY HOME
200;zeo
Reference #:— ,
Grantor(s): (1) rv\!�� (2) Additional on pg.
I — —
Legal Description (abbreviated): Sec---B—Tw11--@
OR Lot lock-_____Ylat
Assessor's Tax Parcel ED#(s): (I)-q737-UXLQU&n-Q- (2)
--Assessor's Tax Parcel rD# not yet assigned
AUTHORIZED FOR RECORDING
City of Edmonds
By: "�� Date: C� 9-)j 06
Page A of-�
WHEREAS, the undersigned owners of property located at ,71�/'j -7?) 4 j�
A u . ,(-/ —9 in Edmonds, Washington legally described
below or on the attached Exhibit A, have applied for a building permit for
compliance and/or to remodel a structure located on the site; and
WHEREAS, the applicant has notified the City of applicant's intention to utilize the
improvements and/or to convert an existing single family structure to an adult
family home; and I
WHEREAS, under the Uniform Building Code the nurn ber of occupants of a
structure trigger certain requirements relating to the fire suppression and exiting
requirements; and
WHEREAS, the City has notified the applicant that the permit will be issued
conditioned on limitation of residents to -- .
D or fewer residents and their
caretakers; and
WHEREAS, the City has issued a permit based upon such representations;
NOW, THEREFORE, the undersigned property owners (liereinafter
"Owner") in consideration of the issuance of a building permit and in order to
confirm the promises upon which such issuance is based while providing notice to
any future owners or mortgagors of the property does hereby stipulate, covenant
and agree as follows:
0 0
I . -Counants Limilalign on Residence. The owner hereby stipulates
and agrees that occupancy of the structure as an adult family home shall be limited
to or fewer adults and their caretakers as allowed by applicable
provisions of state law. The owner acknowledges that in the event that the applicant
seeks revision of the applicant's sta / te license to operate an adult family home with
an occupancy of greater than
-- residents or attempts to rent, lease or
otberwi , se provide residence for additional residents above the
1,7 permitted in the current occupancy classification, the structure shall
be vacated and all residential use ceased until such time as the property is brought
into compliance with the provisions of the State Building Code, under the edition of
the Uniform Building Code then in effect. The owner further stipulates that this
covenant touches and concerns the land so long as the present structure and use
continues and shall run with the land to all future purchasers and assigns.
2. Suboect Tract, The above stipulation and promises shall apply to and
run with the land with respect to a residential structure located at 1 7�4 i �j
A�Vc�— Edmonds, Washington and legally described as:
Lo-r- C4-;,,
3. Notification to Futpre Purchasers and Assignees, This notification
and covenant has been recorded in the records of Snohomish County, Washington
in order to provide notice to any and all future owners of the property of the
limitation at the current level of improvement to single families and adult family
home residents fewer than 11 in number.
4. Enforcement, In addition to any and other remedies civil or criminal
which the City may have, the property owner hereby agrees and stipulates that this
grant of covenant shall entitle the City to enforce by injunction the provisions of this
code and, in so doing, to recover its reasonable attorney's fees and costs.
AUTHORIZED FOR RECORDING
City of Edmonds
BY:262. Da(e:9J-.)AJ00
Page _11 of :�_
DATED this —day of 0�alem 46-11 21 Ooc,
_V_
ACCEPTED BY: APPLICANT/PROPERTY
OWNER:
Jeannine L. Graf
Building Official
Applicant
Appficapt-_'
Owner
NOTIFICATION COVENANT AND
ACKNOWLEDGED:
Mortgagor
NOTARY FOR OWNER SIGNATURES
State of Washington )
. )ss
County of 6
I certify that I know or have satisfactory evidence that _rh+I'Q-n_G 010AP/L"
lie as authorized to execut� the
signed this instrument, on oath stated that he/e-
instrUment and acknowledged it as the QLLL4"n , . (title) of AULh.
raLY:hj 06-me ' name of party on behalf on whom instrument was executed) to be the
free and voluntary act of such party for the uses and purposes mentions in this
instrument. Subscribed and sworn to before me this day of
-1 . - — 1. �UEFI� 7_060 . 1.
NOTARY P. BLIC
STATE OF WAS q yad'u,
COMMISSION EX�Bgy
APRIL 9. 200 ublic in and for the State of Washington.
mis
mission expires
I certify that I know or have satisfactory evidence that U oz�
signed this instrument, on oath tated tha he he was authorized to execute (lie
S ts�
instrume,qt and acknowledged itas the QUWgg, (title) of A4 Lk
FnAIPAgo_ftQ�.ame of party on behalf on whom instrument was executed) to bethe
free and voluntary act of such party for the uses and purposes mentions in this
instFtiment. Subscribed and sworn to before me this 05 day of
q42&_M�A � —,'19 2&0
AN)""i V. xu&41
Notary Public in and for the St te of Washington.
EAly mmission expires
DEBRA L. KARSER
NOTARY PUBLIC
7 L
STPATEOF WASHINGTON AUTHORIZED FOR RIC, CORDING
COMMISSION EXPIRES City of Edmonds
APRIL 0. 2003 By:(�. Date: N_'181(30
-F-9-e-K of
1,:\I'ENII�kRUILDING\FORMS\ADF-COV.I)OC
CITY OF EDMONDS :
k IV FOR INSPECTION CA
PUBLIC WORKS DEPARTMENT- LA Permit Nil?
SIDE SEWER PERMIT 775-2525 Ext.. 220 Issue Date
PERMIT MUST BE POSTED ON JOB SITE
WA�
1. Address oFFonstruction �qqj_�' �7!��TP U ;V I AM W -e S . Ell UW r) ue4
2. Property Legal Description (include all, easements
4111W11'eu) AAA. LA 43 4, 11
3. Single Family Residence Mult�i-Familyu Not of Units
Commercial
4. Owner and/or Builder Vj- beav LoqaAj- i-mc -7�3TM AUC. W
5. Contractor & License No. hk-f CgrA ck?
6. Invasion into City Right -of -Way: No wl' Yes (If Yes Right-of-
way.Construction Permit Required - Call Dial Dig (342-5344) before
excavation).
E-4 7. Cross other private property: Yes No Easement required
attach legal description and county easement number.
READ THE FOLLOWING AND SIGN:
P4
P4
4 a. Property owners must obtain a permit to install side sewers on
>4 their property. A licensed side sewer contractor must be'employed to
construct side sewers in the public' right-of-way.
b. The side sewer contractor assumes full reponsibility for each
installation for one year.
C. Commercial establishment requires a minimum of a six inch (6")
side sewer line.
0 d. Side sewers may not be installed closer than thirty inches ('30")
to any structure.
0
e. Side sewer lines must 0 be laid at a minimum grade of 2% (1.15
0 and maximum grade of 100% (45 ). .. 0
E-4 f. No turn in side s8wer,greater than 45 (1/8,bend) is 0 allowed
between cleanout. All 90 turns must be constructed of a 45 (1/8
bend) and wye with removable cap.
g. No down spouts, footing drains or floor drains can be connected
to side sewer system.
h. Pea gravel is required for bedding when installing sewer lines
through other than granular soil.
i. Cleanouts are required at 30"-60" from each plumbing exit line
and at minimum intervals of 1001 along sewer line run.
j. Trenches within City right-of-way must be restored to original
conditions. Contractors shall be responsible for right-of-way failure
due to poor compaction of fill.
k.. Side sewer must be left uncovered until inspected and approved
by the City.
1. Inspection during normal working hours only. Two (2) working
days notice required.
DATE:
I certify that I ha
irA read
and shall comply w th the above
PERMIT FEE:
CONNECTION FEE:
PERMIT MUST BE
DISAPPROVED BY: Date:
By: Date:
APPROVED By: r7k Date:nZ-
'ON JOB SITE
Ll
0
Side Sewer Drawing
The City of Edmonds EAS-JHIMENT NO - ------------ ........................ ...
NEW CONSTRUCTION REPAIRS F� LID NO . .................. ASM-1. NO . ............... ..
owi\TER, ....... ........................................ CONTRACTOR ----- .. ... .............................................. PER -MIT NO.
JOB ADDRESS .................. LEGAL DESCRIPTION: LOT NO - -------- ---- ............ ... BLOCK NO - -------------------------------- --
..............................................................................................................................................................
NAMEOF ADDITION ------ ............ .....................................................
t I
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Approved:
DATE .... ----------- 3,
- ----------------- - ------------ -- -----
- J- --
PLM- OLLAW
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P P- 0 PF— lzry
4@Fence must be located on private property.
SProperty owner responsible for determining
property lines.
Wence shall not enclose or prevent access to any
City maintained utilities. b
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APPROVED AS NOTED'
BY ENGINEERING,
Date:
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RECEIVED -
CITY COV17 SEP - 3 2003
DEVELOPMENT SERVICES CTR
CITY OF EDMONDS
A
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.,�City of Edmonds Permit NoQZ2W 02!�Oy
R1 G-HT-OF-WAY CONSTRUCTION PERMIT Issue Date: !1[5.,
.11, � V F lw+
X� A. Address or Vicinity of Construction: 14 q is- -C J K 1602- -6
,/ B. Type of Work )e specific): w�_pcAoc__ -7 7.X /sw A p (?>I(. f ,,,>
I C' " ee_ C
C. Contractor: K; 1A A S' PCI-i J!1
Mailing Address: 76�U)sriol--AndOld
Ar 1; Y%j ('V V / 9y;,Z:s
State License #:- A; A q _302"r'f �_10 P ul)
City Business License #:
<Contact: A:JC�CA r mi
Liability Insurance: __ Bond:$
D. Building Perrnit # (if applicable): Side Sewer Permit # (if applicable
E. Commercial Subdivision E] City Project E] EUC (PUD, VERIZON, PSE, COMCAST, OVWSD)
0
Multi -Family ',N000single Family El Other
INSPECTOR:
F. PAVEMENT CUT: El YES 5?NO G. S12jE OF CUT x
CONCRETE CUT: YES El
G.' El Mail Approved Permit �?CallforPickup
APPLICANT TO READ AND SIGN
INDEMNITY. Applicant understands by his/her signature to this application helshe holds the City of Edmonds harmless from
0
injuries, damages or claims of any kind or description whatsoever, foreseen or unforeseen, that may be 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 attorneyfees by reason ofgranting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL
INSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREET PATCH IS
COMPLETED BY CITY FORCES, AT WHICH TIMEA DEBITOR CREDIT WILL BEPROCESSED FORISSUANCE TO THEAPPLICANT
* Traffic control and public safety shall be in accordance with City regulations as required by the City Engineer. Every
flagger must be trained as required by (WAC) 296-155-305 and must have certification verifying co mpletion of the
required training in their 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.
CALL DIAL -A -DIG (1-800-424-5555) PRIOR TO BEGINNING WORK
I HA VE READ THE ABOVE STATEMENTS AND UNDERSTAND THE PERMIT REQUIREMENTS AND ACKNOWLEDGE
THA T I MUS T MAKE THE PINK COPY OF THE PERMIT A VAILABLE ON SITE A T ALL TIMES FOR INSPECTIONS
Signature-,-_2Y,4:-.2_��- Date:
(Contractor or Agent) V
FOR CITYUSEONLYI'��,-.
.4arFe 15
Approved. -by: I I Van" n-11W Rkfifof e:..7*�
D'.is'r'1ft'tiPp Fee Tiind!'I
I Time Authorized: Void After
Special Conditions:
S*ftL ma-r6F' - A -TO, 0ayteaza 11fi Totgl-tfe-."'-�
Rec'*�"_'_'o_-
=.F.;, ofisp- 1jmLj-r1e�.M.ALQUj4a7 �N
M" altMA'r7 r!ne -71) _OLN W
REQUIRED INSPECTIONS: �Fpft L
n
e
Call 425-771-0220, Ext. 1326for a 24-hour voic C sjyection request lin
FINAL APPROVAL OF PERMITTED WO DATE
ector's Signature
C:\Docurnents and SettingsTurtisNy Documents\Fonns\Engnrng\ROWpermit_.doc ' Revised 10/01/03
RETURN ADDRESS:
City of Edmonds, City Clerk
121 5th Avenue North
Edmonds, WA 98020
CONFORMED COPY
200010020237
10/02/2000 11:41 AM Snohomish
P.0003 RECORDED County
NOTICE OF LIMITATION AND COVENANT
ADULT FAMILY ROME
Reference #: 2,00;7t3o
Grantor(s): (1) r*y\ ZCLf�� (2) Additional on pg.—
Legal Description (abbreviated): See --- E3_Twn__P_7 "ng_��Qtr.
OR Lot Block Plat
Assessor's Tax Parcel M#(s): (l)_q'7737_0QD_Q4&ja0 (2)
—Assessor's Tax Parcel ID# not yet assigned
AUTHORIZED FOR RECORDING
REET FILE City of Edmonds
By: IA� — DateNQ 06
Page I of
3WERE �ersigned owners of property located at
ME WN i — __ . __ =
in Edmonds, Washiniton legally described
below or on the attached Exhibit A, have applied for a building permit for
compliance and/or to remodel a structure located on the site; and
WHEREAS, the applicant has notified the City of applicant's intention to utilize the
improvements and/or to convert an existing single family structure to an adult
family home; and
WHEREAS, under the Uniform Building Code the number of occupants of a
structure trigger certain requirements relating to the fire suppression and exiting
requirements; and
WHEREAS, the City has notified the applicant that the permit will be issued
conditioned on limitation of residents to or -fewer residents and , their
caretakers; and
WHEREAS, the City has issued a permit based upon such representations;
NOW, THEREFORE, the undersigned property owners (hereinafter
"Owner") in consideration of the.issuance of a building permit and in order to
confirm the promises upon which such issuance is based while providing notice to
any future owners or mortgagors of the property does hereby stipulate, covenant
and agree as follows:
I t, - , . 1 0
0 i
1. Covenant: Limitation on Residence, The owner hereby stipulates
and agrees that occupancy of the structure as an adult family home shall be limited
to K) or fewer adults and their careta ' kers as allowed by applicable
provisions of state law. The owner acknowledges that in the event that the applicant
seeks revision of the applicant's state license to operate an adult family home with
an occupancy of greater than residents or attempts to rent, lease or
otherwise provide residence for additional residents above the
permitted in the current occupancy classification, the structure shall
be vacated and all residential use ceased until such time as the property is brought
into compliance with the provisions of the State Building Code, under the edition of
the Uniform Building Code then in effect. The owner further stipulates that this
covenant touches and concerns the land so long as the present structure and use
continues and shall run with the land to all future purchasers and assigns.
2. 'Sub-ject Tract, The above stipulation and promises shall apply to and
run with the land with respect to a residential structure located at. f-79 1
A V& - w Edmonds, Washington and legally described as:
c3o L-o-s- c4--,�
3. Notification to Future Purchasers and Assignees, This notification
and covenant has been recorded in the records of Snohomish.County, Washington
in order to provide notice to any and all future owners of the property of the
limitation at the current level of improvement to single families and adult family
home residents fewer than 7- in number.
4. Enforcement, In addition to any and other remedies civil or criminal
which the City may have, the property owner hereby agrees and stipulates that this
grant of covenant shall entitle the City to enforce by injunction the provisions of this
code and, in so doing, to recover its reasonable attorney's fees and costs.
AUTHORIZED FOR RECORDING
ity of Edmonds
By: . Date:n)-." IcX-)
. Page,�L of ::,�_
46'e 20ov
DATED this —day of — I — V1_
ACCEPTED BY:
OWNER:
Jeannine L. Graf
Building Official
1';wldwe�lr #200,780
41cW 1-14evie #_53-2000
NOTIFICATION
NOTARY FOR OWNER SIGNATURES
State of Washington ) -
I )Ss
County of �rohbnitsh) .
APPLICANT/PROPERTY
Applicant
Applicapt-,
r
Owner
COVENANT AND
ACKNOWLEDGED:
Mortgagor
I certify that I know or have satisfactory evidence that ..—Ar +111tiCL OIDAAMVL�
signed this instrument, on oath stated that he/@)Was authorized to execut� the
instrument and acknowledged it as the QLUr%�, (title) of
aLN4 &Wname of party on behalf on whom instrument was executed) to be the
free and voluntary act of such party for the uses and purposes mentions in this
instrument. Subscribed and sworn to before me this /:5 day of
NOTARY PUBLIC
STATE OF WASkINGTON
COMMISSION EXRjgf§r
APRIL'O, 200T
blic in and for the State of Washingto
ission expires 4-c�. 61*3
I certify that I know or have satisfactory evidence that I U
he she w
signed this instrument, on oath stated tha`9 as authorized to execute the
instrume,lt and acknowledged it as the 01)2w,!!L� — (title) of Adjj LL-
&MVA1N&Y4_(-name of party on behalf on whom instrument was executed) to be the
free and voluntary act of such party for the uses and purposes mentions in this
instrument. Subscribed and sworn to before me this t_6 day of
.,"p 2&0
— . 6im, y - Kuk'e'� .
Notary Public in and for the St te of Washington.
Alw-vommission exDires 11�_13
DEBRA L. KARBER
NOTARY PUBLIC
STATE OF WASHINGTON
COMMISSION EXPIRES
APRIL 9, 2003
AUTHORIZED FOR RE, CORDING
City of Edmonds
By: C� e. Date: c) 00
� I Page 3 of -.:�> I
t
L:\TEMP\BUILDING\FORMS\ADF-COV.DOC
CITY OF EDMONDS
CONSTRU . CTION PERMIT APPLICATION
OWNER NAME/NAME. OF BUSINESS—r,47- /��/fi P?
I VJ
ZIP ITELEPHONE NUMBER
NAME
ubt
ZONE PERMIT
Q C, NUMBER
NO. ILID NO.
PUBLIC RIGHT OF WAY PER.OFFICIAL STREET MAP.
TESCP Approved
RW Permit Required
0
EXISTING, REQUIRED DEDICATION
Street Use Permit Req'd
13
Inspection Required
0
PROPOSED
Sidewalk Required
0
W
METER SIZE
LINE SIZE
NO. OF FIXTURES
PAV REQUIRED
YES 13 NO 13
REMARKS
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ADDRESS
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NGINEERING MEMO DATED REVIEWED BY
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CITY ZIP
E NUMBER
IRE MEMO DATED REVIEWED BY
Z
7�
STATE LICENSE NUMBER EXPIRATION DATE
VARIANCE OR CU
ADB#
SHORELINE #
Legal Description of Property - include all easements
SEPA REVIEW
COMPLETE EXEMPT
SIGN AREA
ALLOWED PROPOSED
HEIGHT
ALLOWED PROPOSED
Z
I
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I
EX
W
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (FT.)
FRONT. SIDE REAR
PROPOSED SETBACK
FRONT UR SIDE REAR
�
Property
'"i
LOT AREA
Tax Account
Parcel No.
DATE
9_2,( j —QQ
EINEW W. RESIDENTIAL PLUMBINGIMECH
yy
REMARKS
e0arz I AW =Wen LUL 1 AAjci U5F- Ma
COMPLIANCE OR
ADDITION COMMERCIAL CHANGE OF USE
At"W5 ADS. 4s &- pa"ITMO IIN& ILI A
REMODEL APT. BLDG. EI SIGN
0
COD
GRADING FENCE
REPAIR CYDS. 1:1 1— —FT)
x
EIDEMOLISH WOODSTOVE SW iM POOL
INSERT HOT TUB/SPA
GARAGE RETAINING WALL/
1:1 CARPORT El Y
ROCKER L
HECKED BY TYPE OF CONSTRUCTION
liFH AWA
CODE
2 7
OCCUPANT
SPECIAL INSPECTOR JAREA
REQUIRED
13 YES__
OCCUPANT
LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC 108
57524-1 #
(TYPE OF EXPLAIN:
,VSE, BLISINE OR ACTIVITY
<
-;— ly
NUMFER
OF
STORIES 1 Y2_�
NUMBER O�
DWELLING
UNITS
CRITICA L
AREAS
NUMBER
.17YAuftmev 1,140VX#
DESCRIBE WORK TO BE DONE (ATTACH PLOT PLAN)
FINAL INSPECTION
REQUIRED
VALUATION
FEE
PLAN CHECK FEE
HEAT SOUIRCE�
GLAiIN6
BUILDING
r %
PLUMBING
Plan Check No.
MECHANICAL
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks,
driveways, marquees, etc.) will require separate permission.
GRADINGIFILL
STATE SURCHARGE
Permit Application: 180 Days
STORM DRAINAGE FEE
INS
Permit Limit: 1 Year - Provided Work Is Started Within 180 Days
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"Applicant, on behalf of his or her spouse, heirs, assigns and
successors in interest, agrees to indemnify, defend and hold
harmless the City of Edmonds-, Washington, its officials,
employees, and agents from any and all claims for damages of
whatever nature, arising directly or indirectly from the issuance
of this permit. Issuance of this permit shall not be deemed to
modify, waive or reduce any requirement of any city ordinance
nor limit in 6 11: 1
ENG. INSPECTION FEE
PLAN CHECK DEPOSIT
any Way t e ly s ability to enforce any ordinance
0
TOTAL AMOUNT DUE
hE
I hereby acknowledge that I have read this application; that -the
0
I n forn
information given is correct; and that I am the owner or the duly
ut 0
authorized agent of the owner. I agree to comply �;ith city and
ATTENTI ON
I
APPLICATION APPROVAL
St at a
state laws regulating construction; and in doing the work authoriz.
THIS PERMIT
AUTHORIZES
This application is not a permit until
Lahprovision."
ed thereby, no person will be employed inviolation of the Labor
Code of the Slate of Washington relating to Workmen's Compensa-
ONLY THE
WORK NOTED
signed by the Building Official or his/her
t 0 1
tion Insurance aria RCW 18.27.
Deputy; and fees are paid, and receipt is
S, , T
SIGNATURE'(OWKR OR A ENT) DATE SIGNED
I NSPECTION
DEPARTMENT
acknowledged in space provided.
f11512.0
CITY OF
OFFICIAL'S SIGNATURE DATE
EDMONDS
ATTERTION
CALL FOR
IR E L FAM o B%-.1 DATE
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
INSPECTION
UNTIL A FINAL INSPEc"nON HAS BEEN MADE AND APPROVAL OR
A CERTIFICATE
771-0220
ORIGINAL File
OF OCCUPANCY HAS BEEN GRANTED. USC
— YELLOW — Inspector
SECTION 109
A/.
PINK — Ownp.r rot n acca—,
DATE RECEIVED
F) 1PERMIT
EXPIRES
CITY 7F ZDMONDS
IUSE PERMIT
ZONE NUMBE5,.
CONSTRUCTION PERMIT APPLICATION
JOB SUITE/APT#
ADDRESS Aa
/7�/6_ -7,
OWNER NfAE/NAME OF BUSINESS 1
c ( M P &IJ 0 1 C_ d
PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID FEE III
MAILING ADDRESS
of A,4 f-
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING — PROPOSED
REQUIRED DEDICATION— FT
TESCP APProved
RW Permit Required
Sum t)8e Pannu " I
Inspection Required
Sidewalk Required
Underground
Whing required
CITY ZIP
LA V."Wt A
TELEPHONE
4 V�) U 7
NAME
METER SIZE I
LINE SIZE
7. OF FIXTURES
PRV REQUIRED
YES 13 NO A
13
z
ADDRESS
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
CITY ZIP
TELEPHONE
NAME
&&INC AFYtoyldnolo
(ENGIN"EERING, REVIEWED/DATE
ADDRESS
cc
FIRE REVIEWED BY DATE
ul
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IEL
CITY ZO,
TELEPHONE
VARIANCE OR CU
SHORELINE OR.ADS#
INSPECTION
RE5C
YES No
BOND
POSTED
STATE LICENSE NUMBER EXPIRATION DATE
CHECKED BY
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SEPA REVIEW
COMPLETE EX:�
EXP
SIGN AREA
ALLOWED PROPOSED
I. HEIOHT
I ALLOWED PROPOSED
� / I Af4l
IPROPERTY
TAX ACCOUNfPARCtL �NO.
ok� 00
[j NEW RESIDENTIAL PLUMBING MECH
ADDITION( COMMERCIAL o COMPLIANCE OR
CHANGE OF USE
LOT COVERAGE
ALLOWED PROPOSED
Aw
REQUIRED SETBACKS (Fr.)
FRONT SIDE REAR
;75" -7.5' 151'."
-PROPOSED SETBACKS (Fr.)
FRONT.- LIRSIDE REAR
A-f-!4#,4A0jF
PARKING
RE" I PROVIDED
LOT AREA
jAFPR_d!I(
PLANNING REVIEWED -BY DATE
,kREMODEL 0 APARTMENT 1 0 SIGN
0 GRADING 0 FENCE
REPAIR CYDS x Fr)
REMARKS
DEMOLISH [3 TANK [j OTHER
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CARPORT ROCKERY RENEWAL
(TYPE OF USE, BUSKSS OR ACTIVTM EXPLAIN: A;r-fAfhj
hf6j:i�ZZYA4 — �;�B .
CHECKED BY
TYPE
1
CODE
1-6117
OCCUPANT
GROUP
NUMBER
OF
—STORIES
NUMBER OF
DWELLING
UNITS
CRITICAL
AREAS
NUMBER
SPECIAL INSPECTOR
REQUIRED [3YES
3
e0FUCTION
AREA
51:::
OCCUPANT
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS'INSPECTIONS'PERL UBC 108/FINAL INSPECTION REQV
AWL WAII
VAWATION $
+
Description �'FE E Description FEE
Plan Check
0 GLAZING 11 LOT SLOPE % . %u1IdI'**''
PLAN CHECK NO: VESTED DATE jPlumbing-'
4Z:%�K
/9 /_ :2 Mechanical
THIS P r Mm_nR K NOTED. THIS PERMIT COVERS WORK TO
It BE DONE ON PRIVATE PROPERTY ONLX ANY CONSMUCTION ON THE PUBLIC
23 DOMAIN (CURBS, SIDEWALKS, DRWEWAVS, MARQUEES, ETC.) WILL REQUIRE Grading Recording Fee
t: SEPARATE PERMISSION.
.sR4-ddfv0'ie-V City Surcharge
PERMIT APPLICATION: ISO DAYS - - qr
PERMIT LIMM I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS a W. ilin's d"n State Surcharge
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS Traffic Mitigation Plan Chk Deposit
IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Review Receipt #
ALL CLAIMS FOR DAMAGES OF WHATEVER MATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMrr. ISSUANCE OF THIS PERMIT SHALL NOT BE Fire Inspection Total Amount Due
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE Crr1fS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
z
Landscapelnsp. Receipt #
I HERE13Y ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF APPLICATION APPROVAL
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- This application Is not a peffnit until signed by the
TION: AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or 1110er Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt Is acknowledged In space provided.
WORKMENS COMPENSATION INSURANCE AND RCW 18.27.
IGNATU R AGENT) DATE SIGNED 1A135) ATU DATE
11716 zE2
IL / 0 0/ 00 / //OAVI�9,
771-0220 RELEASED BY /DATE
Ai=rtNT!6N M 1333 Al 1A A. 1 1. /.1
�A�
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL z6ffffdw"
A FINAL INSPE&ION HAS BEEN MADE AND APPROVAL OR A CERTIFI_ 771-0221 _LL / L�
CATE OF OCCUPANCY HAS BEEN GRANTED. USC SECTION 109 ORIGINAL - FILE . YELLOW - &SPEc*'TOR
10/01 FM PINK -OWNER - GOLD - ASSESSOR