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21008 76TH AVE W
ADDR---,�S: 7--,-
TAX ACCOUNT/PARCEL NUMBER: -016"— 016
60L
BUILDING PERMIT (NEW STRUCTURE): I IN -�
COVENANTS (RECORDED) FOR:
CRITICAL AREAS:- q -5 -r� �� DETERMIN ' AT ION: E] Conditional Waiver 0 Study Required /�'Iaiver
DISCRETIONARY PERMIT #'S:- AO 43 7 7- 9"1 � 0 --410 - F49
DRAINAGE PLAN DA
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
ON
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pp� FW 4 101 M,
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED:
SEWER LID FEE LTD liq
SHORT PLAT FILE:
LOT: BLOCK:
SIDE SEWER AS BUILT DATED:- <V(F1e)S- lZalzQ5-
SIDE SEWER PERMIT(S),#: I ) q 9
GEOTECH REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
WATER METER TAP CARD DATED:
OTHER:
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and I th a.I.am the owner, or the�duly authw-1: AT NT ON, APPLICAT16N"APP OVAL!''i'�-:.
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IF�d agent of the ownti. I agre to�'.Om;flir�wfth city and late laws regul. t PERAIii -not a;permlt. Unt.jj�'
12ting.construction;. and, In. doing the work authorized thereby..io person;�. Thii:-��plidtlorj �js'
by: the Diiector of, Buildinj Iniip�e!6
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NOTE: PERMIT, LIMIT -ONE;YEAR: e6elpt
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R INSPECTION
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DEPARTMENT,
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CITY OF
�:.DATE
J.PLOT PLAN CHECK & APP�P/VIEO' ELMIONDS
Pit C-1107
INSPECTOR
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CA(SE NO.
Critical Areas Checklist.
Site Information (soils/topography/hydrology/vegetation)
I Site Address/Location: 21008 76th Ave, W, Edmands, WA 98025
2. Property Tax Account Number: 6143.�000 — 015 � 0107
3. Approximate Site Size (acres or square feet): 99,865 s.f.
4. Is this site currently developed? x yes; no.
If yes; how is site developed? Existing I —story
5. Describe the general site topography. Check all that apply.
X 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 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):
6. Site contains areas of year-round standing water: No Approx. Depth:
7. Site contains areas of seasonal standing water: No ;Approx. Depth:
What season(s) of the year? - N/A
8. Site is in the floodway N/A floodplain N/A of a water course.
9. Site contains a creek or an area where water flows across the grounds surface? Flows are year-
round? N A Flows are seasonal? NIA (What time of year? N/A
10. Site is primarily: forested meadow ;shrubs mixed
urban landscaped (lawn,shrubs etc) X
11. Obvious wetland is present on site: No
For City Staff Use Only--
:1. Site is Zoned? -4-1
:2. SCS mapped soil type(s)?ALPMOoot� VX*414 LAM9 e4M"R� fp-& X
3. Wetland inventory or C.A. map indicates wetland present on site? o
-4. Critical Areas inventory or C.A. map indicates Critical Area on site?
15. Site within designated earth subsidence landslide hazard area?
.6. Site designated on the Environmentally Sensitive Areas Map?
DETERMINATION
STUDY REQUIRED
W ER
Reviewed by- T 0�_
Planner
CONDITIONAL WAIVER
Date
Rev 0009/93
V 90 .194 -
City of Edmon&
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 subject property. The
information needed to complete the
Checklist should be easily available from
observations of the site or data available at
City HO (Critical Areas inventories, maps,
or soil surveys).
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
development permit application.
With a signed copy of this form, the
applicant should also submit a vicinity map
or plot plan for individual lots of the parcel
with enough detail that City staff can find
and identify the subject parcel(s). 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 Area Checklist and attest that the answers provided are
factual, to the best of my knowledge (fill out the appropriate column below).
Owner / Applicant:
.-Bnb Rebm, AdmiMiRtyatny
Name Edmonds Care Center
21008 76th Avemile West -
Street Address
Applicant Representative:
XQUO. AfA
Name �Architects - Reie . d - Reinvald
201 N- T Street
Street Address
Edmonds, WA 980251, 2061778� 107 Tannma, WA 9R403, 2061572-3993
City, State, ZIP Pho'ne City, State, ZiP Phone
12Z10793 12110193
Signature Date SignatfieU Date
0
S PERMIT N 0 0
City of Edmo n-d 0: '0.
PERMIT EXPIRES
�c3
1 s9c
Address of Constructio* n: ' *2 1009-6 1 LID #
k4 300010GO 1
Property Tax Account Parcel No.
Attach 'copies of all access and utility easements. Verified and Approved b
Owner and/or Contractor: UW44�SIT�j' M-ECHAnhrA I— 00AIERA CIDL5 -
Contractor License #: QfQ I LIS'
Ej Single Family
F� Muiti-Family (No. of Units
aCommercial (No. of Units
F] Public
"lobBuilding Permit
10 b&
Invasion into City *Right -of Way: Yes No
*RW Construction Permit.#----
Cro�s other "Private Property: El Yes N No
�ktach legal description and copy of recorded easement.
Owner/C`ontracto_� A*lzo�5_
Owner or contractor signature and acknowledgement statement: Date.
By signing for this permit I certify that I have read the City's public handout entitled
'ide Sewer. Specifications, and shall comply with all City requirements outlined therein.
ALL DIAL -'A -DIG 5555) BEFORE ANY EXCAVATION W
.9 C (1 - 8 0 0 - 4 lyiw
FOR INSPECTION.CALL 425-'771-0220 exten'siola. �w
.......................
. ....... FOR OFFICE USE ONLY
.... ......
... .. ....... .. ..
Permit F69 $ :506.0 01)Repair Fee Issued By:. ILL.
Date lssue'd": .(31141 U_�
77
Assessment Fee $ Receipt No:
City Permit Surcharge Fee 045.00 T i otal Fi i es Paid $
e
NOTE: IF JOB SITE IS.NOTT READY. FOR INSPECTION WHEN,
INSPECTOR ARRIVE ' S.A.$45 RE -INSPECTION FEE WILL BE CHARGEDi, -
JobSite Read yYES NO' —Date: Initial:
Partial Inspection: Date: Initial:
P p
artial Inspection: Date: Initial:
fINAL INSPECTION APPROVED: Date: Initial: As -built to Street File:
PERMIT MU! BE POSTED ON JOB SITE
White Copy: Fie Green Copy:'Inspector Buff Copy: �pNic!nt
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