21021 PIONEER WAY.PDFIiiiiiiiiiiiii
12828
21021 PIONEER
WAY
ADDRESS:
TAX ACCOUNT/PARCEL NUMBER: 00
BUILDING PERMIT (NEW STRUCTURE): - HIM— MW
COVENANTS (RECORDED) FOR:
CRITICAL AREAS:. OA OS-45 — DETERMINATION: E] Conditional Waiver El Study Required XWaiver
DISCRETIONARY PERMIT #'S:
DRAINAGE PLAN DATED: 1411S/b
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED
PERMITS (OTHER):
PLANNING DATA CHECKLIST DATED:. 4 1 is L65
SCALED PLOT PLAN DATED:
SEWER LID FEE $: LID
SHORT PLAT FILE: LOT: BLOCK:
SIDE SEWER AS BUILT DATED: Cl /c� (p / 6 to
SIDE SEWER PERMIT(S) #: "'15
GEOTECH REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
FOR:
WATER METER TAP CARD DATED:
L\TEMP\DS'rs\Fom1s\Street File Checklist.doc
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CONSTRUCTION PERMIT APPLICATION
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re S!
PLAN CHECK FEE
BUILDING
PLUU48ING
MECHANICAL
T:iis Permit covers work to be done on
nRADtHW.LL
Any construction cn the public domain (curbs, sidewalks..
driveways, marqu 3, etc.) will require separate permission.
STATE SUP.CMARGE
Permit Application: 130 Days
ENEPOYCODE
Permit Limit'. I year - Provided Work is Started Within 180 Days
-Applicant. on behalf of his of her Spouse. neirs. assigns and
hold
successors in Interest, agrees to InderrIntfy, defend and hold
narmless the City Of Edmonds, Washington, Its oflICI315,
employees. and agents from any and all claims for dOM8905 Of
whatever nature. Vising directly or Indirectly frorn the lesUance
issuance of this perml!. shall not be deemed 10
PLAN CHECK 0 EPOSn'
of this permit.
modify. walvO Or resuce any requirement of any City oraInance
nor limit in any way the City's ability to enforce any ordinance
TOTAL AMOUNT DUE
provision."
I hereby acknowledge that I have ro*d thls appl!callon; that the
ATTENTION
Information given is correct; and that I am the owner. or the duly
authorized agent Of the owner. I agree to comply with city w,d
THIS PERMIT
state laws regulating congtruction: and In doing the work outhorIZ-
will be employed In violation of ths Labor
A014CA1.15
ONLY T"r.
ad thereby. no person
Code of the State of Washingtun relating to Workmen's Compensw
WORK NOTED
lion InsuronC0.
OINS"CTION
INT
SIGNAT�RE HER OR AGEN j
AffENTIOW
IT IS UNLAWr-UL TO USE OR OCCUPY A BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS --tFEN MADE AND APPROVAL OR
A CERTIFICAiE OF OCCUPANCY HAS BEEN GRANTED. UBC
CHAPTER 3.
, 14:
15
AM ISM
04 age-
74
APPLICAMN APP
This RPPIIC8tW 14 not & pe� 11millil
dw,
sign,od by th*� Building OtWId I
00puly: and to" we pw. VW . . lie
acknowledged In SPWO PlrOvkf*&
<
DATE
'JDA
OPICINAL - File YELLOW - lns;*ctot U
PtNK - Owner GOLD - Assessor
JAN-18-2005 16:10 0 0 P.20/49
020
Critical Areas Checklist CA File No:
Site Information (soils/ topogmphy/hydrology/ vegetation)
1. Site Address/ Lncatio= 2-1 C, 2-�
2. Property Tax Account Number. oo 74 6- rjoojonoc-)
3. Approximate Site Size (acres or square feet): 1;2-
4. Is this site currently developed? X yes; — no.
If yes; how is site developed? L-1-StWAQ Y-E %PE-AC-E-
5. Describe the general site topography. Check all that apply.
Flat: less dun 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
ove r 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. Approx. DeptIt
7. Site contains areas of seasonal standing water: Approx. Depth:
What season(s) of the year?
8. Site is in the floodway — floodplain of a water course.
9. Site contains a creek or art area where water flows across the grounds surface? Rows are year-round?
Flows are seasonal.? — (What time of year?
10. Site is primarily: forested meadow shrubs mixed
urban landscaped (lawn, shrubs etc)
11. Obvious wedand is present on site -
For City Staff Use Only
I - Plan Check Number, if applicable?
2- Site is Zoned?
3- SOCS mapped sod Wpe(s)? /-\I(A 6
4. Critical Areas inventory or CA- map indkatm Critiml Area on site7A7j7_,n I I pM \,, r, 2- VA(-, V� lr-i V
5. Site within designated earth subsidence hindslide hazard area? N-4 n
1-1 . t 1 -12 +
%-j- 4-421C42-1- ( - i
DErERMINATION
MUDY REQUIRED WAJVER
Reviewed br. natm
0itical Aras ChmMV3.25.2004
JAN-18-2eO5 16:10
City of Amonds
Development Services Department
Planning Division
Phone: 425.771.0220
sgq Fax: 425.771.0221
TU Critical Areas Checklist contained on this form is to
be filled out by any persou preparing a Developirgnt
Pcmut Application for the City of Edmonds prior to
his/her submittal of the application to the city.
7"he purpose of the Checklist is to- enable City staff to
determine whether any potential Critical Arms are, or
my be, present on the subject property. Ile information
needed to complete the Cheoldist should be easily
available fiom observations of the site or data available at
City Hall (Critical areas inventories, maps, or soil
surveys).
P. 19/49
Date Received: -121WIL11-1)
City Receipt #: ' 'ZkVj& /
Critical Areas File c;) 000- 00—�ZK:
Critical Areas Cheddist Fee-.— $135.00
Date Mailed to Awlicant: Va.W—
A property owner, or hisiber authorized representatme,
must fill out the checklist, sip and date it, and submit it
to the City. The City will review the checklist make a
Precursory site visit, and nuke a determination of the
subsequent steps rmcssary to complete a developmcnt
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 pertincnt
information (e.g. site plan, topography rnap, etc.) or
studies in conjunction with this Checidist to assistant staff
in completing their prelirninary assessment of the site.
The undersigned appficant� and his/her/its heirs. and assigns, in consideration on the processing of the application agmes
to release, indetwify, defend and hold the City of Edmonds harmless fi-orn any and all damages, including reasonable
attorney's fees, arising finm any action or infiwfion based in whole Or Part upon false, misleading, inaccurate or
incomplete informtion furnished by the applicant, hLs4w/its agents or eniployees.
BY MY siguatw-e, I certify that the informtion and exhibits herewith submitted are true and correct to the best of my
knowledge and that I am authorized to file this application on the behalf of the owner as listed below.
SIGNATURE OP APPLICANTtAGENT
DATE
Property, Owner's Authori=tion
By my signature, I cerhfy that I have authorized the above APPlicant/Agent to apply for the subject land use application,
and grant my permission for the public officials and the staff of the City of Edmonds to enter the subject propaty for the
Purposes of inspection and pos ting attendant to tion.
SIGNATURE OF OVINW DATE 3 12- q
ko
Owner/Applicant:
MNIT4i-TVACA�- 0oo-QL&S—
Name
-2A 02, 1 F(0AtT,—V= sLt&�[
Street Address' a. I
ma ADS WA, 9 J�p
City
state Zip
Tclephone:__(1A2-5- ) -11(e 3 1- 'S 2—
Email address (optional):
Applicant Representative:
Naine
Street Address
city state Zip
Telephone:
Email Address (optional):
III
00
CD
Ln
cl�
CITY of EDINNO S
For Inspection Call 771-3202
Address of Construction:
Property Legal Description (Include all ea
DAW 1-07, Z)
ODE S-EWER PERMIT
PERMIT'NO. 07571
ents 6—t
Owner and/or Builder: 6 0
LU
cc
Contractor & License No:
Singl:e Family Residence
Multi -Family (No. of Units
Commercial (No. of fixture Units
Invasion into City Right -of -Way: No Yes (if Yes, Right -of -Way
Construction Permit reoui.red. Call One -Call -Center (1-800-424-5555) before any
excavation.)
Cross other"Private Property: No Yes (If Yes, easeme.nt required,
attach legal description and county easement 'number.)-
PLEASE.READ'-THE ITEMS LISTEDON, THE CK
t6v 11L
I cei"�ffy that I haq 'read and sha\l I comply Date
with the items lisad on the back.
�Vzzzz III
.Zzz
050
WAWI ;j;0I AIAI Al Al 5011AI Al-11AII'l W1 Ul All
==1 /=00/104=�
Permit Fee: 'Issued By:,
.Trunk Charge: Or-) bate Issued:
Assessment Fee: Receipt No.:
Partial Inspection:
Comments
Final Inspection Approved:
Date In iti a 1
Rejected:
Reason
PERMIT MUST BE POSTED ON JOB SITE
Wh-ite Copy File Green Copy - Inspector
Date Initial
Date Initial
Buff Copy - Applicant
Side Sewer Drawing
The City of Edmonds EASEMENT NO - --------------------------------------------
NEW CONSTRUCTION [M REPAIRS E] LID NO - ------------------ ASMT. NO . ..................
OWNER ....... FlOttAE-F—R --- N4,k,�f ----------------------- CONTRACTOR - ----- CQ0�� ........ 7
-------------------- PERMIT NO. .......
JOB ADDRESS .2 ..... S44AV-40-0-0 .... 140-1,Ae
LEGAL DESCRIPTION: LOT NO - ----- 8 ----------------------------- BLOCK NO - ---------- - -------- --------
MOM%
--------------------------------------------------------------------------------------------------------------------- ..... TREA PLANT
.IMENT ............
NAME OF ADDITION ...... Pt --Al - ----- jQr: ... SEP�w-00-D ...............................................
2,10 11
4VIDP.
r
0
3'
41)p.
C-0 CAP
Approved:
B, 4&-f ..... ..................................
PWW-0001-1 1/75 (REV. 11/78) DATIYA..,2 r�
011117
. . 0 0
PLANNING DATA
NAME: OZ"j I A-f -DATE: �-?ag
SITE ADDRESS: ?- 1 0 el - P, �*� k�" PLAN CHK#:—o!s, - / 24
PROJECT DESCRIPTION: A AA;�;m ,/- A -2-0 z -t 4, /2-- A,4k 1"r^-Ae4 0A 16Z-*-
REDUCED SITE PLAN PROVIDED?: (jes)l No)
MAP PAGE: 2-oS' CORNER LOT: (Yes FLAG LOT: "I
ZONING:_ AS-8 - CRITICAL AREAS DETERMINATION #: 05 -497
LJ Studv Reauired:
LlWaiver
ElConditional Waiver
SEPA DETERMINATION:
QFee
L1 Checklist
LlAPO list w/ notarized form
Ll (Needed for 500 cubic yards of grading, Shoreline Area- site within 200 ft. of Puget Sound or Lake Ballinger)
Exempt
SETBACKS:
Required Setbacks:
Street: 2-5' Left Side: Right Side: Rear:
Actual Setbacks: -1.
Street:. �4' LeftSide: RightSide: Rear: 7/'
Street map checked for additional setback required? (Yes I (Noj DNA)
LJ DETACHED STRUCTURES: rVr'4' f k-d^
U'ROCKERIES: i., - , o�,e 1,;' f��t F1 P�1�4
L] FENCEsrrRELLISES: C-�L (j-,
Ll BAY WINDOWS4 PROJECTING MODULATION: Yv-", szksi'itj
21* STAIRS/ DECKS: a (U-((, , --*7 4-e"V-,6Vj
PARKING: Required: 7,- Actual: -
LOT AREA: 15,45 2-'
LOT COVERAGE 2-633.5-
Calculations: ��i S- z- -7 '7�
BUILDING HEIGHT: /
2 1
Datum Point: 'rap A-rAj�,, N%An k-j, K F0�4f6atWum Elevation: 6 4
Maximum Allowed: 2-5' Actual Height:
A.D.U. CREATED?-( �/Yes)
SUBDIVISION: m5.
LEGAL NONCONFORMING LAND USE DETERMINATION ISSUED: (Yes
OTHER: N-i- rw-sn!.), -
(IV, I— — A— i-hj ( 0-- ,Z k.-- —
ryl W-Cm'-17.
Plan Review By:
NewBPPIanningDataForrn.D0C
0
STATEMENT OF PLAN REVIEW SERVICES AGREEMENT
&
ACKNOWLEDGEMENT OF REQUIRED
14? 1
DISCRETIONARY APPROVALS V fly
10001
1, am the owner/agent for the owner, fd?&�
building pen -nit to construction 1rhKrovements upon real property located at:
in Edmonds, Washington. I acknowledge that, pursuant to terms of this agreement, the Building Permit
Application I have submitted will be accepted for review by the City concurrently with the review of any
necessary discretionary project permits or approvals required by the provisions of the Edmonds
Community Development Code. I also acknowledge that the City shall not accept an application for
building permit that is not complete as determined by the minimum submittal requirements published by
the City which I have read and understand. In signing this form, I acknowledge that I have submitted all
necessary documentation in order to make a complete application for a building permit. The City
determined that the discretionary application(s) for this project were deemed complete on (date).
I acknowledge that any plan review fees paid in connection with this application are solely for the
expenses and costs associated with review the plans as I have submitted them, and do not entitle me to
any right or claim to the issuance of a building permit. In consideration for the consolidated review of the
building permit application concurrently with any required discretionary project permits or approvals, I
hereby acknowledge and agree to be bound by terms and conditions of this agreement as. set for herein.
1. The required discretionary project permits or approvals for this project currently include, but are not
limited to the following:
0 Architectural design review ........................................... Hearing date:
.................... Hearing date:
.................... Hearing date:
.................... Hearing date:
n Variance ......................................................................... Hearing date:
—>rCritical areas determination or variance request ............. Hearing date:
.F] Other (specify) Hearing date:
Subdivision or short subdivision
E] Planned residential development
n Conditional use permit .................
I further understand that additional discretionary project permits or approvals may be determined
during the course of discretionary project review which may affect plan review timelines and plan
review fees paid for this building permit application.
2. Any building permit issued and approved for this project will be subject to any conditions or
restrictions imposed pursuant to the review and approval of any required discretionary project permits
or approvals. Such conditions or restrictions may require that the building plans I have submitted be
modified or amended to be consistent with such conditions or restrictions. I understand that additional
plan review fees will be required in the event that modifications or amendments to the plans
submitted are required by conditions or restrictions imposed pursuant to a final decision to issue or
grant any required discretionary project permits or approvals. In the event that modifications or
amendments are required, the owner shall be solely responsible for any and all costs which result
therefrom, including, but not limited to, additional full plan review fees. When additional plan review
fees are required, the fees shall be paid in full prior to the commencement of additional plan review
by the City.
No building permit will be approved or issued until such time as a final decision for all required
discretionary project permits or approvals have been. issued or granted, including the expiration of all
appeal periods. A decision to issue or approve any required discretionary project permit or approval
shall not be considered final until the limitations period for any appeal has expired or until all
administrative and Superior Court appeals have been resolved. In the event that an appeal of a
discretionary project permit or approval results in new or additional conditions or restrictions which
require modifications or amendments to the building plans, such conditions and restrictions shall be
treated as if originally imposed in the issuance or granting of the discretionary permit or approval.
However, new full -plan review fees shall be required.
4. The building permit application shall expire 180 days after the building permit submittal regardless of
whether a final decision, including'expiration of appeal periods, for all discretionary project permits
or approvals have been issued or granted. I understand that I may request a building permit
application extension for an additional 180 days, in wiiting, if filed before the expiration of the
original application. The City may grant only one extension. In the event that the building permit
application expires prior to a final decision on the issuance or approval of all required discretionary
permits or approvals; or if not request for an extension is submitted in writing prior the expiration. of
the original application, then the application shall expire and a new application and new full -plan
review fees will be required.
5. In the event that any application for a required discretionary project permit or approval is withdrawn,
or if such permit or approval is denied either by the City or upon appeal, no portion of any plan
review fee shall be refunded by the City.
6. In the event that the building permit applicant initiates or requests amendments or modifications to
the building plans after plan review by an applicable City Department is complete, new full -plan
review fees will be required and shall be required to be paid in ftill prior to the commencement of
additional plan review by the City.
I certify that I have read and understand the terms
services and agree to be bound by such.
provisions of this agreement for plan review
Date:
statement of plan review sery agree.doc
01.17.2001
2
FIOKJCEF-� WAY
5,5,000
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ADDITION FOR: MATT 4 TRACIE DOUOLAS
21021 PIONEER NAY, EDMONDS NA 15026
PHONE: (425) 1-16-5252
PROJECT DATA: REMODEL/ ADDITION
OC,CUPANC'Y' SROUPS: R5
CONSTRUCTION TYPE: \/-B
ZONINC-7: R55
TAX PARCEL #00'74e) 0000OObOO
TH15 PROJECT SHALL COMPLY NITH
THE POLLONINC-7 CODES: 2005
2oo5 NsEc, 2005 VIAO, 2oo5 upc., r=cvc.
LE&AL DESCRIPTION:
LOT e>, PLATOF 5EANOOD AS RECORDED
IN VOLUME 47 OF PLATS, PIS. 5 4 (b
S 1/2, SV4114 SEC.101, T. 2-1 N., R. 4 E., N.M.
5NOHOM15H COUNTY, NA5HINOTON
BUILDIN& AREA:
EX1571N& MAIN FLOOR (HEATED): 161(b s.f.
EXI571N& LONER FLOOR (HEA7ED).- 450 9.f.
EX1571NC7 LONER FLOOR (UNHEATED): 450 s.f.
PROPOSED LONER FLOOR (HEA7Er,* 202.5 s.f.
TOTAL HEATED FLOOR AREA: 22qa.5 s.f.
TOTAL BLDC7. FLOOR AREA. 277a.5 s.f.
EX15TINC7 HEAT: FORCED HOT AIR - ELECTRIC
ADDITION HEAT: ELECTRIC HALL HEATER
LOT INFORMATION:
LOT AREA: 15,452 SF
LOT COVERA5E �^V PROP05ED: 2655.5 SF (11%)
LOT COVERA6E 4 IMPERVIOUS AREA RATIO:
EX15TIN(5 ROOFFRINT AREA . 22(ba s.f. (14.7%)
PROPOSED ROOFFRINT AREA � 217 s.f. (1.496)
NALKNAY5/ DRIVENAY/ PATIO: abc! s.f. (5.6%)
TOTAL IMPERVIOUS AREA: 5554 s.f. or 21.1%
F S
tkh E
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SL OPE CA L CS:
RANG
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END.
1
0.00
10.00
2
10.00
20-00
3
20.00
30.00
4
30.00
40.00
5
40.00
50.00
6
50.00
60.00
AREA
2713.33
PERCEN
18.2
6404 ' 08
42.9 1 0'\\
2813.22
1429.47
18.9
9.6 it
1
1004.54
6.7
557.03
3-7
VERTICAL DATUM:
ASSUMED
SITE BM11 I: TO.
STORM DRAIN MANHOLE
ELEV: 100.84
HEIGHT CALCS:
(3) 114. 0'
(9 121.5'
0 108.6'
(D 110.3'
AVERAGE GRADE= 113.6'
ACTUAL= 137.4'
MAXIMUM= 138.6'
CONC
WALK
lip"
rn Pr\�---
' I - -ic
e ui Actual
NO. ' t
sicw
PIONEER WA Y
ftHARD sm. ARCHITECT$, Pf- 200�-�,
N,37'00'JO"E &
69.29'
p
.--104-
5FORMER WA TER METER
,gRA IN
CA TCh
METE)�
--25-'-0"- SETBACK
-108 ----------------
WOOD FENCE
BASIN FENCE COI IS
1-30' SO�ITH
PROP. Ll NE-
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TPIC
IPANEL
EXISTING
21021 PIONEER WA Y
SNO. COUNTY
TAX PARCEL,N0.
007480000A
Q600
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4
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----------- ---------
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MAR
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-- PERMIT C094
PJnTMr RMEW CRECWST
PROJMT ADDRESS:
PFAHM HAM, 21021
APPLIChTION RECEIPT DAM
Reviewed by: (initial/ �te)
PLANNING
Su ENGMG
WrRISWR I .
BUILDING
7/777777
7777-7777
SINGLE FAMILYMULTIPLEVCOMWIAL' - (Circle.Crne)
Z
SETBACKS CHECKED Plaming
17111111177777777
-ITIT171
VARIANCE/SMMCK'ADJ.;'l
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-177171rl-
71-ITII1711
MMITIONAL USE PERMIT:"��'.',:
2
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-
ADB'REQUIMMS CHECKED
3
Omm ZONING ��REKEM
111171
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1111111171
4
4H111111
FMIRCNMENTAL FTATURES
5
ACCESS SLOPE VEHICLE ACCESS
11171111
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6
7TTTIT77
77T77T7
DRAINJ= PLAN (On Site) 4el- L
//////
/////////
////////
7
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7 T/T/ T/7
STREET FILE
8
777777
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LEGAL DESCRIPTIM VERIFICATION
/////////
////////
9
QUM' CLAIM/DEDICATIONS
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FASEMW - PUBLIC/PRIVATE
/////////
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CALCULATE SEWER CONNECTION IF NO LID#
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//////
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/////////
////////
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T1 7 77
PLAT/SUBDIVISICN RHQUIREMENrS
13
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RIGM-OF-WAY CONSTRUCTION PM41T REQD
/////////
/////////
14
1.
7777F
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BOND REM FOR PUBLIC IMPROVEMENTS
SOILS CONDITIONS & GROUND
777777R777777T/T
WATER FIELD CHECKED
16
TfTF17
_7777777/T
STRMV PAVING REQUIRED
17
T77TF7
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CURB AND GUrM REQUIRED
18
SIDEMUX REQUIRED
19
7 T1 77
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CURB CVr FOR DRIVEWAY REQD
20
STRELV NAME SIGN REDD
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/////////
/////////
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7TITIT
7777T/-//W
—
MEER SIGNING REQD
22
TITIV
177111171
TT17TT17T
SIDE SEWER AVAILABILITY
//////
/////////
/////////
23
EXISTING WATER MAIN SIZE lu/uterjl�!e In
TIT1777T911111
p!(4!5'
1111111T
////////
TTIT77777
24
77/77777
111711
T171-TIT177
WATER METER SIZE
////////
25
///77777
11111IT97
SERV7CE LINE SIZE
////////
26
777777TI7
7777TT17
7777/-=
—
HYDRhW RELVIRED
27
_11YU
7TfIZMT
HYDRANT SIZE EXISTING
//////
/////////
28
CFMS CONNECTICN INSPECTIM REQD
'777777
//////
T,,T,)T,4?Tg
/////////
7 777777
17717—
29
T/7777
//
7777777T77
11ATER METER 01ARGE MOD
17 // //
//////////130
PYRE LIM CflARGE REM SPRINKLER
////////
31,
STREET CUT
32
OPEN DITCH EXISTING
777TI77TI777TI7
/////////
/////////
33
REM
111117TIT
7777=
V7
CULVE3?r REM_
35
SIZE
7 7 77 7
7TI T/7 T1 77
7 7 7 7 7 7 7 7
36
CAMi'' BASIN REM
77777T/V
All
37
J. INDICATED ON SITE PLAN
38
SHOULDER DnhlMGE MhrNrA=,.
IlIfft
17717
777777777
SIMU OPM RUNOFF
39
MISC..
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177111111
40
rn
REVIEM BY.
PLANNING lv=. HNGIN RING MGR. PUBLIC WORKS MGR.
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
NAME (OR NAME OF BUSINESS)
15e_&UL)D6k
ADDRESS
651
7EITY TELEPHONE NUMBER
-Ser �)_ 1 7 7,Y 7 a Gi
, � (e-
WA-ME
M C_ lua I- An n /�s
DRESS
VQ,jy,1 / (9 /
FITY TELEPHONE NUMBER
Z &_tk e
;AME
jj�$CX /—fI30f&!S __,I 0(7
IPO 8 6K L / / 1�5 �;_
cITY-5ea7Y/,e Fc`x,�j I TELEPHONE NUMBER
7 7jl' 73 (o
FATE LICENSE NUMBER
—se-a-LooAl, CD
Legal Description of Property - Include all easements
(show below or attach four copies)
USE 'MWPERMIT
ZONE NUMBER
JOB
ADDRESS ZIOZ / R1o*-eejf__ lIW,6Y
LEGAL DESCRIPTION CHECK[ SUBDIVISION NO. LID NO.
/,P/- 9 1 'p- I Ile
PUBLIC RIGHT F WAY PER OFFICIAL STREET MAP.
Ze
EXISTING REQUIRED DEDICATION
PROPOSED
IRIGHT OF WAY CONSTRUCTION PERMIT REQUIRED 0
STREET USE PERMIT REQUIRED 0
SEE ENGINEERING MEMO DATED
� 1-a-4-1fol
1 Z-67,?0 oy pl-Al 6-//*, 1
.P NEW
RESIDENTIAL
PLUMBING
MADDIALTER
COMMERCIAL
MECHANICAL
E] REPAIR
1:1 RETAINING WALL
SIGN
DEMOLISH
REMODEL
EXCAVATE
1:1 OR FILL
PRE -MOVE INSPJ
COMPLIANCE INSP.
FENCE
E] I x _FT)
swim
POOL
FWOOD STOVE/
I INSERT APT.BLDG
M RENEWAL
NUMBER OF STORIES NUMBER OF
DWELLING
[UNITS
'UTURE OF WORK TO BE DONE (ATTACH PLOT PLAN)
re S;
METER SIZE IBUILDING SUPPLY SIZE IFIXTURE UNITS
REMARKS
SIGN AREA ENV. REVIEW ADB NO.
ALLOWED I PROPOSED COMPLETE I EXEMPT SHORELINi
____FDATQ
VARIANCE OR CU PL-ANNING REVIEW BY 0
YARDj5W jr;t- f
DE _r-' I HEIGHYJLOTCOVEIJAGE
FRONT REAR Z_r, os 21
BY TYPE OF CONSTRUCTION
I Tr —Al
SPECIAL INSPECTOR
REQUIRED
0 YES 0 NO
PLAN CHECK FEE
BUILDING
PLUMBING
MECHANICAL
This Permit covers work to be done on private property ONLY.
GRADING/FILL
Any construction on the public domain (curbs, sidewalks,
driveways, marquees, etc.) will require separate permission.
STATE SURCHARGE
Permit Application: 180 Days
Permit.Limit: 1 Year - Provided Work Is Started Within 180 Days
ENERGY CODE
"Applicant, on behalf of his or her spouse, heirs, assigns anck
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
PLAN CHECK DEPOSIT
whatever nature, arising directly or Indirectly from the issuance
of this permit. Issuance of. this permit shall not be deemed to
modify,.walve or reduce any requirement of any city ordinance
nor limit in any way the City's ability to enforce any ordinance
provision."
TOTAL AMOUNT DUE
I hereby acknowledge that I have read this application; that the
Information given is correct; and that I am the owner, or the duly
ATTENTION
authorized agent of the owner. I agree to comply with city and
state laws regulating construction; and In doing the work authoriz-
ed thereby, no person will be employed In violation of the Labor
THIS PERMIT
AUTHORIZES
ONLY THE
Code of the State of Washington relating to Workmen's Compensa-
WORK NOTED
tian Insuranco,.,
5?AATURE (9WNER OR AGE DATE SIGN�ED
I NSPECTION
DEPARTMENT
CITY OF
EDMONDS
h
VALUA
0
CODE HEIGHT
Ma
OCCUPANCY OCCUPANT
GROUP AV& LOAD
ue6
S /* �-
-1tv, 00
APPLICATION APPROVAL
7
This application Is not a permit until
signed by the Building Official or his
Deputy; and fees are paid, and receipt is
acknowledged In space provided.
OFFICIAL'S SIGNATURE DATE
0
Z
cr
W
W
Z
0
Z
W
cr
W
Z
Z
ATTENTIOW 771-3202
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED. UBC
CHAPTER 3.
102-78
RELEASED BY:
DATE
ORIGINAL — File - YELLOW — Inspector
PINK — owner GOLD — Assessor
ME140 TO:
FROM:
SUBJECT:
Building Division
Planning Department
Engineering Division
Public Works Department
�1,6
DATE
After revie-a of the -subject Building Permi.t ap*pl ication, vie- have the Following
cori-iments
1 'Connection to City wa ter system required.
2. Connection to Ci ty san i Lary sewer sys tem reqii i red
3. Right-o F-way permi t requi red for any work on C i ty property .
4. Driveway slope not to exceed 111%
5. Back,.-iater valve required if downstairs plumbing is below elevation of
dpstr6am manhol'e .
6. Wa -- . er and se-wer 1 i nes to be s epa ra Led by 10 - Foo t mi n imum
WF&
00 6/82