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21301 95TH AVE W.PDFIII - 111111111 9265 21301 95TH AVE W DATE RECEIV6 1PERMIT EXPIRES CITY OF EDMONDS U USE Z ZONE P�R U M T�,4 IN MEIE CONSTRUCTION PERMIT APPLICATION 'ON JOB JA' sun'E/AFr# ADDRESS OWNER KAMUNAME OF BUSINESS 213ol c-Ij 01 PLAT NAME/SU8DrVISION NO. LOT NO. DO NO. MAILING ADDRESS UD FEE S 7k I 17s- a PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP An —I R. — C ITY I EXISTING PROPOSED— finst u" Pw,n A� F-� __`*" ITELEPHONE S AIJV_� _71,.533 -7 REQUIRED DEDICATION— FT u—g—i — w�g'N�sd NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED I I YES 13 NO C3 "DRESS REMARKS U OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAI.AGE CITY ZIP TELEPHONE NAME ENGINEERING REVIEWEDIDATE ADDRESS 1019A &i5am&A U_tzq jui-� 07-&0 CITY ZIP TELEPHONE FIRE REVIEWED BY DATE STATE LICENSE NUMBER EXPIRATION DATE I 01ECKED By VARIANCE OR CU SHORELINE OR ADBA INSPECTION BOND CL-)5_M00031PAj ID 'sEPA —REVIEW ES NO r3YREO'�(No PC PROPERTY TAX ACCOUNT PARCEL No. COMPLETE ', EXEMPT SIGN AREA ALL D HEIGHT Al BE 00qS_.S_e700000 c2co EXP NEW RESIDENTIAL C3 PLUMBING MECH LOT COVERAGE ALLOWED REQUIRED SETBACKS (Fr.) FRONT R PROPOSED SETBACKS (Fr.) ADDITION COMMERCIAL C E OR FRONT L/R SIDE R 1_ 1 COHAMNPGLIEANOCF USE 104/ REMODEL APARTMENT SIGN PARKING REDID LOT AREA N PLAN ING REVIEWED BY D 01� REPAIR 0 GRADING 0 FENCE CYGS ( _ X FT) REMARKS DEMOLISH TANK OTar, — _75' GARAG f-AW muyr SIC Fey,-f hL E [3 RETAINING WALL o z CARPORT OCKERY RENEWAL WVF6X7Y WH 67 (TYPE FUSE. BUS11; EXPLAIN: C.E. ,, ITYPE OF CONSTRUCTION CO,� OCCU PANT NUMBER NUMBEROF CRITIC I' jjj I GROUP OF D ING WELL TAR A 8 SPECIAL INSPECTOR OCC 0 STORIES UNIT a NU B R R OUIRED E YES JAREA LOAD DESCRIBE WORK TO BE DONE REMARKS PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D as L 6' 1 120 VAWATION $ &4Uxa-Am4 Description FEE Description FEE Plan Check T RCE GLAZINd % LOT SLOPE % Building PLAN C�� VESTED DATE Plumbing — - — Me" hanical THIS PFRZrr ZTNQR=S ONLY THE WORK mcrem THIS PERMIT COVERS WORK TO BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC Do MAIN SIDEWALKS, Grading Recording Fee (CURSS, DRIVEWAYS, MARQUE WI RE UIRE ES'ETC LL a SEPARATE PERMISSION. Engr. Review City Surcharge PERMIT APPLICATION: 150 DAYS ERMIT LIMIr. I YEAR - PROVIDED WORK 15 STARTED WITHIN 100 DAYS Engr. Inspection State Surcharge 7 BE ;E BACK OF PINK PERMIT FOR MORE INFORMATION 'APPUCANT. ON BEHALF OF NO OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS Traffic Mitigation Plan Chk Deposit IN INTEREST, AGREES TO INDE.1,111, DEFEND AND HO I HARMLESS E CITY OF L, EDMONDS, WASHINGTON. ITS OFFICLkM EMPLOYEES. AND AGENTS FROM ANY AND Fire Review Receipt # ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY FROM THE ISSUANCE OF THIS PERMR. ISSUANCE OF THIS PERMIT SHALL NOT BE OT L E DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Fire Inspection Total Amount D,ue 0 NOR LIMIT IN ANY WAY THE Crry'S ABILITY TO ENFORCE ANY OR_ .0 dOF Landscapainep. Receipt # I KERE13Y ACKNOWLEDGE THAT � HAVE READ TH APP -ATION; THAT THE INFORMATION IS LIC GIVEN IS CORRECT. AND THAT AM THE OWNER. OR THE DULY AUTHORIZED AGENT APPLICATION APPROVAL E THE OWNER. I AGRE TO COMPLY WITH CITY AND STATE LAWS REGULATING CON UC. CALL Tin applicallonis nua penTkh untillWad by the TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYUEC BuIlding-0m.cial w hwhw Dep �Y: �d Fan we paid. aM _D V E LA CODE 01,111CSTATE bF WASHINGTON RELATING TO FORINSPIE CTION pt Is acknovAedged in space provided. E_. Cc RKMEN' P _TI�NSU dE D RCw 18.27. V _ DATE ESIGN-ATURE OKE—jolfffr) DATE V13NEDj (425) 771-0220 DATE ATTENTION W 1333 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- CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FAX ORIGINAL - FILE - YELLOW -'INSPE6TOR PINK - OWNER GOLD - ASSESSOR 10/01 Critical Areas Checklist CA File No:-. 09�, 15 Site Information (soils/ topography/hydrology/ vegetation) 1. Site Address/Location: - 2 13 Q 1 9 S TH 6-Vig W Elb ivoS jv.4 qFo2 C 2. Property Tax Account Number: — 0044CS*Y00QQQe00 3. Approximate Site Size (acres or square feet): P. V 0 4. Is this site currently developed? — Cyes�/ no. If yes; how is site developed? APR 2 5. Describe the general site topography. Check all that apply. PERMIT (""OUNTEIR �Flat- less than 5-feet elevation change over entire site. ____.RpUing:,_.slopes on site generallv less than 151/o.(a. vertical rise of -3.0-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 or, 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: rV 0 Approx. Depth: 7. Site contains areas of seasonal standing water: -_ r--1 0 ; Approx. Depth: What season(s) of the year? ____ �///_ 8. Site is in the floodway floodplain of a water course. 9. Site conoins a creek or an area where water'flows across the grounds surface? Flows are year-round? A/40 Flows are seasonal? — (What time of year? 10. Site is primarily: forested : meadow shrubs mixed urban lan��ei(lawnshrubs etc) 11, Obvious wetland is present on site: -M- Use qn�y or. 5iaff 14 LIP Itet is id 10 Aik V"F 64nS ltj�v�_ % A� ia Ind N4 Ctitlea A- A -? on git� fW�"tkal rea -t !d, A Iff q� J; 1. .1 IL Vj Critical Areas Check . list CA File No: 0A, 16 Site Information (soils/ topography/ hydrology/ vegetation) 1. Site Address/Location: S o I 9S 7H A -Vie W Ebmoivay jyA e?(Fv2 0 2. Property Tax Account Number: — 0 OQ 05"? 0 0 00 0 2 0 0 3. Approximate Site Size (acres or square feet): SOS S r RE C E VED 4. Is this site currently developed? _(yes- _/ no. APR 2 2 29,92 If yes; how is site developed? 0 k- 5. Describe the general site topography. Check all that apply. PERMIT COUNTER — (=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: rV Approx. Depth: 7. Site contains areas of seasonal standing water: rxJ 0 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 an area where water flows across the grounds surface? Flows are year-round? A/4) Flows are seasonal? (What time of year? 10. Site is primarily: forested ; meadow shrubs mixed urban landscaped- aawnshrubs etc) 11. Obvious wetland is vresent on site- A-1 6 �JM�ai rmvaz E D 0V —41 monds- City of Ed 7. 71- 1 . ''. I Development Servic es Department Planning Division" 1. Phone: 425;771.0220 1JC. 1 %9,11 The Critical Areas Checklist contained on this form -is to be filled out by any person preparing a Development Pertnit 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 poten ' t * ial 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 Hall (Critical areas inventories, maps, or soil surveys). Date, Received: "i 2-Z 'Q -2— 'City Receipt M 1 _P>K 2— Critical Areas,Filel#,: Critical Areas Checklist Fee: $45.00 Dolfe'Waileid to Ap . olicant: --� � proiperty.iowner, or his/her''authorized representative, must ill-iout the -checklist, sign and date it, -andsubmit it to the City. Ile City will review the checklist, make a precursory site visit' and � mak6 a determiinatibn� of the ,subsequent steps �necessary to q6inpietd'. a development permit application. ?lease 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 6 f 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, hii/hei/its agents or employees. By my signature, I certify that the information and exhibits heriw*ith submitted a ' re true and correct to the best of my knowledge and that I am authorized.to file this application onihe behalf of the owner is listed below. SIGNATURE OF APPLICANT/AGENT DATE Property Owner's Authorization By my signatureJ,cer* 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 property for the purposes of inspection and posting attendant to this applicati on. SIGNATURE OF I PLEASE PRINT CLEARLY Owner/Applic.ant: Mim ML � Name. 2 13 01 q5rl-1 Akz VJ Street Address ,,Fbm'olvo� WA- `IeOP, c city State Zip Telephone: '7ql- 5-3 V7 Email address (optional): �V//_ DATE Cq— OV— 0,�e Applicant Representative: Name Street Address City State Zip Telephone: .. Email Address (optional): Critical Areas Checklist.doc/3.19.2001 -OATERECEIVED -OD I PERMIT EXPIRES /0 -Z2 CITY OF EDMONDS USE I ZONE PERMIT NUMBER CONSTRUCTION PERMIT APPLICATION JOB S E ADDRESS 2 If )Vj C15", Alt OWNER NAMEINAME OF BUSINESS zd "Cf� SA /4' PLAT NAME/SUBDIVISION NO. I LOT NO- L D NO, LIDIEEI IJALINGADDRESS 0 PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP EXISTING — PROPOSED TESCP App—so W A I,— !;.. Stl Ui,. P—d ese d C In.p."lle, "sd-ed a CITY ZIP TELUHONE'\ FIE.UIRE..E.ICATI.N— IT U-9—nd 0 NAME IL ML ILR SIZE I LINE 1111 1 NO. 01 FIXTURES REQUIRED YEPRI S 0 NO 1:1 ADDRESS REMARKS z OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE 0 -5moE4 dt4-e-4&Aj K4e- �'Vbd Ache CITY ZIP TELEPHONE NAME,./ All chevI`Aovm-< ENGINEERING REVIEWEDMATE ADDRESS 0 FIRE REVIEWED BY DATE Z CITY ZIP 0 TELEPHONE STATE LICENSE NUMBER EXPIRATION D77� VARIANCE OR CU SHORELINE OR ADB# INSPECTION D OYREO ES �60 'HEIGHT 1,10 OSTED T PROPER?� SEPA REVIEW COMPLETE EXEMPT SIGN AREA ALLOWED PROPOSED ALLOWED PROPOSED 0 �4VOU _00 EXP 0 NEW S 103 LOT COVERAGE REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT.) UMBING I MECH ALLOWED PROPOSED FRONT SIDE REAR FRONT LJR SIDE REAR AUDITION o COMPLIANCE R CHANGE OF USE PIE. PARKING PROVIDE. L07AREA ING VIE)N DATE �44 rE "7 REMODEL SIGN C3 REPAIR 0 GRADING FENCE CYDS X _FT) RIMARKSR.... OTHER _ WAr DEMOLISH TANK ,�7mrs LAw ipeempm L=AL Fzr-�7c, C] GARAGE M RETAININGWALL CARPORT I, , ERY C:] RENEWAL 01 USE. BUSINESS OR ACTIVITY) EXPLA;�: CHECKED By YPE OF CONSTRUCTION OCCUPANT �PE 06./:�� 7 A-17 �Z IVC/� e"01111 Jai- "rq-v 414, ICODE 17)- G ... P NUMBER OF NUMBEROF —.LLIN. 1 CIT11 AL AREAS SPECIAL INSPE F OCCUPANT 10 STORIE S UNITS NUMBS REQUIRED C3 YE S JAREA LOAD DESCRIBE WORK TO BE DONE REMARKS PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D r�S 5 f 7 A VALUATI.� FEE PLAN CHECK FEE HEAT SOURCE GLAZING % LOT SLOPE BUILDING 1 PLAN CHECK NO: PLUMBING 0_:352_ jV11TEO DATE MECHANICAL THIS ERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE Is U BLIC GRADING/FILL D . I OMAIN (CURBS. SIDEWALKS. DRIVEWAYS, MARQUEES, ETC) W LL REOWRE SEPARATE PERMISSION. STATE SURCHARGE PERMIT APPLICATION: 180 DAYS A, 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. HEIRS, ASSIGNS AND SUCCESORS END, INSPECTION FEE IN INTEREST, AGREE S TO INDEMNIFY EFEN. AND HOLD HARMLESS THE IT' OF LANDSCAPING 2 EDMONDS, WASHINGTON, ITS OFFICIALS. EMPLOYEES, AND AGENTS FROM ANY AND INSPECTION FEE ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT a E IRECEIPT DEEMEDT MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINAN E PLAN CHECK DEPOSIT 0 0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. IR CEIPT/60:;7_ 7 X7 TOTAL AMOUNT IDUE _0 I HEREBY ACKNOWLEDGE THAT � HAVE READ THIS APPLICATION; THAT THE INFORMATION GIVEN IS CORRECT. AND THAT AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF APPLICATION APPROVAL THE OWNER. I AGREE TO COMPLY WITH CIT AND STATE LAWS REGULATING CONSTRUC-This application is not a p0lmil unfil signed by ZhO CALL TION AND IN DOING THE WORK AUTHORIZ ED THEREBY. NO PERSON WILL BE EMPLOYED B�'j ding Otfi,W .1 hi./hel D.P�ly: end F... — PsId. end IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION '*ceipI is cknowI*dg0d,,, SP.CG p—ded. WORKMEN'S COMPENSATION INSURANCE AND RCW 16.27. OFFICIALS SIGNATURE DATE SIGNATURE TE NED/ 7qf DA) >- GENT) �SIG (425) �ED 'SW C_ c C.- 771-0220 (R�E L E A S BY DATE ATTENTION -- EXT 333 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 OFOCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FAX PINK - OWNER - GOLD - ASSESSOR 5198 I III: v ill, 11,111,11,11:1 STA-ft' �Ivr I I 1 1: 1 � ( 0 q I � 6 ji: 1:1 !:"::11:!, � 1 1:11 0 F 4 "' I N 0 1: HEALTH PROFESSIONS QUALITY ASSURANCE DIVISION Till CERTIFIES THAT THE PERSON OR ESTABLISHMENT NAMED HEREON IS AUTHORIZED AS PROVIDED BY LAW AS A ADULT FAI'l 1 HOME V I DU A L I.rVE K 11 1, r% IR '73A LFRED0Vjq,, `5TH W EDMONDS WA 9,(3 0 SECRE '�ARY� NUMBER v 0,29f;-'-C��5 p DATE Iss LIED EXPI TION �D ATE 99 v PERSONAL Copy OF YOUR LICENSE I i STATE OF WASHINGTON HEALTH PROFESSIONS QUALITY ASSURANCE DIVISION ADULT -Atr LY �qOMF pp T DE P, 1NDIVID J. ACTIVE KITSAK, LARTSA At-FREDO"44A 915TH AVC- Iq EDMONDS WA 9E:, 2,a SEC -----NUMBER SI�E�CRETARY CJ._.g _I 9( 9 9 C1 EXPZtrotton Dole FP C) C,.:) 9- C-9-16-0-iD RETURN ADDRESS: City of Edmonds, City Clerk 121 5th Avenue North Edmonds, WA 98020 NOTICE OF LIMITATION AND COVENANT ADULT FAMILY HOME Reference#: letmir 2-006163 Grantor(s):(l Z4kT6,4-A-'*r'L-_r4 Z4/;24hitionalonpg.— Grantee(s): City of Edmonds Legal Description (abbreviated): Sec�Twn--?--:i�---Rng Qtr OR Lot_ 2 lelyl,�Ile 46--e-S Plat C7 Assessor's Tax Parcel ID#(s): (1) (2) --___Assessor's Tax Parcel ID# not yet assigned AUTHORIZED FOR RECORDING City of Edmonds By: X6 Date: 6-27- Page I of '-? WHEREAS, the undersigned owners of property located at Z,1301 , 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 WHEREAS, under the Uniform Building Code the nurn her of occupants of a structure trigger certain requirements relating to the tire suppression and exiting requirements; and WHEREAS, the City has notified the applicant that the permit will be issued conditioned on limitation of residents to 4 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: 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 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 state license to operate an adult family home with an occupancy of greater than 11- residents or attempts to rent, lease or otherwise provide residence for additional residents above the . 4- — 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. Subiect Tract, The above stipulation and promises shall apply to and run with the land with respect to a residential structure located at Z/30/ 2-5-11ve it/ , Edmonds, Washington and legally described as: 2- 61c,112,ile AeAc--� 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 -6- 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: �M6 Date:-z--z2-1V 1 2, Page -.L 0 _. DATED this day of -179 ACCEPTED BY: OWNER: Jirannine L. Graf Building Official NOTIFICATION NOTARY FOR OWNER SIGNATURES APPLICANT/PROPERTY Applicant Applicant �' �wne- r Owner COVENANT AND ACKNOWLEDGED: Mortgagor State of Washington ) � )ss County of illaL�' I certify that I know or have satisfactory evidence that signed this instrument, on oath stated that hc�q was authorized to execute the instrument and acknowledged it as the— (title)of Firam (1�4 ho/ye(name of party on behalf on whom instrument was executed) to be the free an'd voluntary act of such party for the uses and purposes mentions in this instrument. Subscribed and sworn to before me this day of X NCtarf Public in aiWfor the State of Washington. My commission expires ?, I certify that I know or have satisfactory evidence that signed this instrument, on oath stated thatg�she was authorized to execute the instrument and acknowledged it as the (title) ol`2� �62 ame of party on behalf on whom instrument was executed) to be the free a d voluntary act of such party for the uses and purposes mentions in this instrument. Subscribed and sworn to before me this day of , t9--2 c� . 0— J. 'hfry Public in and Wr the State of Washington. 9 ;ommission expires 14 0 y AUTHORIZED FOR RECORDING City of Edmonds By: Date: 6-7-L-0 Page 3 of 3 L:\TEMPkBUILDINGTORMS\ADF-COV.DOC APPLICATION for SIDE SEWER PERMT The City of EdmondsO I r ETFILE NEW CONSTRUCTION REPAIRS 0 EASEMENT No . .................................... 111-06500 OV,`NER .......... Tom McGowan Sr. --------------------------------------------------------------------------------------------------- CONTRACTOR .................................................................................................. PERMIT No . ........... .......... ADDRESS ------ �1_3.0.1 ..... ... 9-5th ... Av.e 14 .................................. .............. LEGAL DESCRIPTION: LOT No . ...................... ----------------------- BLOCK No . ............................................ .. .. .... .. ..... .. . . . 0 NAME OF ADDITION Dye Tested Or Sewer,1972 Approved: DATE................................................ By ...................................................................... DATEO C> AGING AND ADULT SERVICES ADMINISTRATION DMMM"M OF FIRE SAFETY EVACUATION PLAN oa �&HFA" WAC 388-76-200(l 1) An Adult Family Home shall have a posted plan for evacuation to safe areas in event of fire. Draw a diagram of the floor plan of your home in the space proveded below. Indicate escape mutes and designate where staff and residents should meet outside the residence. Indicate the location of fire extinguisher(s) and smoke detector(s). lNb I KUL; I IUM: rrovioer/Hesiaent amr,v6I R 00 1*4 rib:l FA MIL R O.OH 5 T 0 /� A (;�E BATH i to W �4 ana posts in a conspicuous location. )-SMOI�E- �DErECrO X E 50poomr -r-rM&U,- /3 ED A OOH Z- 01"4-f BA SEMEIVT 'EIMER, C UA MEH 7rT", IV -It #T77ECEIVED 10-2-2--W ] 10[PERMIT -OD EX PIRES CITY OF EDMONDS ZONE NUMBER ve'000, USE PERMIT 2DO(W f CONSTRUCTION PERMIT APPLICATION JOB S TFJ PT# ADDRESS 'f OWNER NAME/NAME OF BUSINESS —r'.s PLAT NAM E/SU BDIVI SION NO. LOT NO. LID NO. /i A.- LID FEE $ 5 MAILING ADDRESS PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved 0 RW Pennit Required j z V� C^ 0 EXISTING — PROPOSED Street Use Pernift Req'd 0 Inspection Required 0 Sidealk Required 0 CITY ZIP [TEI_711�14E' J_S f)( 771- ,"7-13 7" REQUIRED DEDICATION— FT 1 Underground 1 wiring required 0 NAME f METER SIZE LINE SIZE NO. OF FIXTURETPRV REQUIRED 0 YES 0 NO 0 3 ADDRESS REMARKS z z OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE a z CITY ZIP HONE NAME P c11e"V)LA�0VPA4_C ENGINEERING VIEWED/DATE ADDRESS m FIRE REVIEWEDBY%f%fjjjj IMIA, I WTE Uj CITY Z IP TELEPHONE l'- z M IL 0 VARIANCE OR CU SHORELINE OR ADB# INSPECTION RECQD , BOND IPOSTED STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY 0 Y1 x 0 SEPA REVIEW COMPLETE EXEMPT SIGN AREA ALLOWED PROPOSED 'HEIGHT PROPOS ALLOWED ED PROPERTY TAX ACCOUNT PARCEL NO. tol- -00 w EXP C] NEW VIRESIDENTIAL 0 PLUMBING MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.) ALL OWED PROPO SED FRONT SIDE REAR FRONT UR SIDE REAR 0 ADDITION 0 COMMERCIAL COMPLIANCE OR CHANGE OF USE z PARKING LOT AREA BY DATE REMODEL C3 APARTMENT SIGN REO'D I PROVIDED 4NGEVVE REPAIR C] GRADING FENCE X CYDS _ FT) MARKS Ramr,--ml WAr, -3a&,-7(,,j5o OTHER <,;-,fA1-F_ LAW PPJ--- EM M LOCA(- RV-�Cni,, ff�( DEMOLISH 0 TANK lvtf Z GARAGE RETAINING WALL RENEWAL CARPORT ROCKERY OF USE, BUSINESS OR ACTIVITY) EXPLAIN: CHECKED BY TYPE OF CONSTRUCTION OCCUPAN GROU PkA FE �PE 7 A/7 —/ 0 ro'"4041091yzif NUMBER OF NUMBER OF DWELLING F" CRITICAL AREAS I M 1 n 0 M SPECIAL INSPECTOR JAREA OCCUPANT 0 STORIES UNITS NUMBER REQUIRED 0 YES 1 LOAD 4 DESCRIBE WORK TO BE DONE REMARKS PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D 5 kd L� 711 _V-" OOCV 10 Y 7_0 z--- ZA4 C`7— 14�p ("I T y U-9 Acss u'v 44 ot L' 6 0) VALUATION FEE PLAN CHECK FEE E GLAZING % LOT SL BUILDING NO: VESTED DATE w'-35Z PLUMBING MECHANICAL THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC GRADING/FILL N1 E M DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE j SEPARATE PERMISSION. STATE SURCHARGE w PERMIT APPLICATION: 180 DAYS PERMIT LIMIT: 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS ENG. REVIEW FEES SEE BACK OF PINK PERMIT FOR MORE INFORMATION in APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS (a ;N ENG. INSPECTION FEE uj INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF _j 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 0 PLAN CHECK DEPOSIT _j DEEMED To MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE 0 NOR LIMIT IN ANY WAYTHE CITY'S ABILITYTO ENFORCE ANYORDINANCE PROVISION.- X, TOTAL AMOUNT DUE RECEIPT /00, 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 DO NG THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED It 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 receipt is acknowledged in space provided. 1-1—IN'S COMPENSATION INSURANCE AND RCW 18.27. OFFICIALS SIGNATURE DATE SIGNATURE� WW GENT) DATE SIGNED (425) 7- 71 1220 7 -C R ELEASED BY DATE ATTENTION EXT 333 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 FAX PINK -OWNER GOLD -ASSESSOR 5/98 0 E ot RECORD OF INSPECTIONS INSPECTOR DATE APPROVED SETBACKS ..................... FOUNDATION: Footing ...................... Wall.......................... Pier/Porch ................. Retainirig Wall ........... Slab Insulation .......... PLUMBING: Underground ............. Rough -In ................... Commercial Final ...... HEATING: Gas Test .................... Gas Piping ., ............... Equipment ................. Commercial Final ....... EXTERIOR SHEATHING NAILING .......................... FRAMING ........................ FIRST FLOOR FRAMING ... INSULATION ................... Floor Insulation ......... Wall Insulation ........... Ceiling Insulation ....... SHEETROCK NAILING ... SPECIAL INSPECTION ... MISCELLANEOUS .......... FINAL APPROVAL FOR yy\s -CIO OCCUPANCY .................. 'r t RETURN ADDRESS: City of Edmonds, City Clerk 121 5-th Avenue North Edmonds, WA 98020 CONFORMED COPY 200009180219 09/18/2000-10:25 AM Snohomish P.0003 RECORDED County NOTICE OF LINHTATION AND COVENANT ADULT FAMILY HOME Reference#: letm i r # 2-00603 Grantor(s): (I) Z ART.,S KNA14 KITSAY, A9ditional on pg. Grantee(s): City of Edmonds Le . gal Description (abbreviated): Sec�Twn —_Rng--Z--Qtr /14E- t 67 OR 1,0_ 2- Block Pla' lew441e- 4,-44-� Assessor's Tax Parcel IM(s): (1) (2) Assessor's Tax Parcel ID# not yet assigned AUTHORIZED FOR RECORDING City of Edmonds By: SL26 Date: Page I of WHEREAS, the undersigned owners of property located at Z-13,01 , 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 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: 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 — 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 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. Subject Trgict. The above stipulation and promises shall apply to and run with the land with respect to a residential structure located at Z/30/ IS-4ve. It/ Edmonds, Washington''and legally described as: 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 -�— 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: JM Date: 1 Page 2— of S DATED this day of az,�az�Sl— ell ACCEPTED BY: OWNER: KA4-� - Jeannine L. Graf Building Official NOTIFICATION NOTARY FOR OWNER SIGNATU�ES APPLICANUPROPERTY Applicant %.-p VV U UJI - -W W1619 U-0-0 ACKNOWLEDGED: Mortgagor State of Washington \)ss County of I certify that I know or have satisfactory evidence that IACIS7,9� signed this instrument, on oath stated that heKso was authorized to execute the instrument and acknowledged it as the (title) of -Mf- 6?0� FRm i A4 hoeVe (name of party on behalf on whom instrument was executed) to be* the free a n'd voluntary act of such party for the uses and purposes mentions in this instrument. Subscribed and sworn to before me this //A*d,ayof IW(aa5l' Nota4 Public the State of Washington. My commission expires �2'- / -- 2 - fy that I know or have satisfactory evidence th I certi at a-4�1 signed this instrument, on oath stated thatolie was authorized to execute the instrument and acknowledged it as the (title) ofA�� dt�i�A- 11��'L'qname of party on behalf on whom instrument was executed) to be the free add voluntary act of such party for the uses and purposes mentions in this instrument. Subscribed and sworn to before me this dav of 0 tAOTAR), WWY Pw� in and tdr the State of Washington. n expires AUTHORIZED FOR RECORDING City of Edmonds By: JZA Date: 0—Z-�L-00 I Page 3 Of .3 1 L:\TEMP\BUILDINQFORMS\ADF-COV.DOC