21506 96TH AVE W.PDFiiiiiiii iiiiii
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21506 96TH AVE W
ADDRESS: IZ-1 �zj —0[&�
TAX ACCOUNT/PARCEL NUMBER:
BUILDING PERMIT (NEW STRUCTURE): -
COVENANTS (RECORDED) FOR:
tJOW qb03 -21 dA- pL
CRITICAL AREAS: DETERMINATION: [] Conditional Waiver Study Required F-1 Waiver
DISCRETIONARY PERMIT #'S:
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
PERMITS (OTHER):
PLANNING DATA CHECKLIST DATED:
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 #:
WATER METER TAP CARD DATED:
OTHER:
L:\TEMP\DST's\Forms\Street File Checklist.doc
-CAFiJeNo: CQ_kA_f_
Critical Area's Ch6ckl 't;
is
Site Inf6. ti6h (s'6ils/,topograph�./`�ydrolo''g'y'�/����,'��iC-ge'tAti'on)�
1. 5ito'Address/Location: U) 6rDWM0 5� LA31q q
2. Property Ta:k'Account Nuriibet: _Z>0773-Z�; 00� 0 1�900C:j
3. re feet):,,
proxurtat6"Site: Size (acres or, s,�qui a 3 i 5
4. Is this site currently developed? yes; no.j��
if yes; how is,site -developed?.
iheg" topography. Check- that 4 ap * ply: '
5. Destiiijo en
Flat:, less'. than 5-fee,, elevationthan oyer entire site.
ge, .
Rolling: sk oes on sA0 I ge ; n'er y ess
or. than 15% (atvertical rise of 10-feet over a -horizontal
distance'bf 664eot).,
ki
Hilly: sl4es: present. on site of'.'
e than.15% and less than 30% a vertical rise of 10-feet
over a honizon,tal distance' of.33 to. 6i�ieet).
Steep: grades'6f greAtok than- 30 %'present on site (a vertical rise of 10-feet over a horizontal
distance -of loss than �3-fee't).
Other (please describe):
6. stan
Site contaim area,s..of year -;round ding:w'ater:.,,:- - pprox.,Depth.-�-'
7.- Site!tont6ins areas of seasonal 9fitfiding"Witer" Approx. Depth'
What season(s) of the year?
8. Site is in the floodway,
floodplain
of a water course.
9. Site contains acreek6ri. an area where,water flows across the grounds surface? Flows are year-round?
""Flows art seasbnal? -jWhAt time of year?
10. Site is
.I primarily: forested meado shrubs n-dxed
urban I�ndsca f � � ` i � i W I I I ;�, i Zil,
,,,pf (Iai�'.nshiubseb,4.
11. Obvious wetland is present on site:
7.
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04 17 M, N. _71
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Critical Ateas Che&list.60. 19.2001
The Critical Areas Checklist -contained 'on this form is�-td A prpper,_ty,*6wner, or his/her authorized representative,
.an
be filled.out by any person preparing a Development., "date iti;"aiid' submit it
Permit Application for. the City' 'of Edmonds prior to,
to the City. II-e -Cit . will�re� the checklist .,make a
y
his/her submittal of the application to the City. pyedu'rilsory 'site" 'visit, 'andi, ie�'determihation of the
The purpose of the Checklist is to enable'City stiff to
determine whether any potential Critical Areas. are,:,or,
may be, present on the subject property. The information
needed to compleie the Checklist should be. , easily
available from observations of the si tt'or data available at
City Hall (Critical areas inventori,4, S, or, soil
surveys).
PPQ -
The undersigned applicant, and his/b6r/its heirs, and..assigns,.m consideration on the processing of the application agrees
to release, indemnify, defend and'hold the City of Edmonds—Iiiiiiiiiis-ft6in any and all damages-,'inicluding reasonable
attorney's fees, arising from any action or infraction based in,whole, or part upon ;false, misleading, inaccurate or
. % .1. -
incomplete information furnished by the applicant, his/her/its agents:or employees.
By my signature, I certify1i1hat the information and exhibitshereWith submitted are true and correct to the best of my
knowledge and that I am authorized to fi le- this alp-pilatibfi. o*n the behalf Of th6 owner as . listed- "dlow,
SIGNATURE OF APPLICANVAGENT DATE.,
Property Owner's Authorization
By my. signature, I certify that I have.a.uthorized the above-Appli . cant/Agent to, apply for the subject-lafid usp',a0p)ication,
and grant my permission for the public officials and the staff of the City of Edrnonds'to enter the subiectp''r6pertyfor the
purposes of inspection and posting attendant to this application.
sse%luvnL--*LFps necessaryflu 'COMPICLe a.development
pertrut-applica.tio'n.
SIGNATURE OF OWNER
Owner/Appficant:
. �bfN
Name
�, o '(�>o X, G (4
Street Address
e�t�4� 5 L")
city State Zip,.
Telephone: 0<-Lr,- 5`3
Email address (optional):
Critical Ai6s Checklist.docl3.191001
Please submit a vicinity map,- along with the signed copy
of this form to assist City staff in,finding and locating th6
specific 'piece of property described, on this, form. In
ddditiOn,"t'he ,applicant �shilf include other pertinent
information (Cg. site plan, -tppogra etc.) or
p
'hy map,
'studies, in conjunction with this'Checklist to assistant staff
i ' nc ; o4letiri g L 'their preliminary assessment of the' -site.
DATE
Nani*'
'StreetAd,dress
State Zip
'Pity"
Tqjep�on.e:
Erniil-A�ddr-ess'�oiptional):
OF EDMOMM WASHINGTOL
BUILDING PERMIT
dmwin6k ind suFacicnt de�;"15 tO 61d'atr
this CC& zTc amLchcd haum
bu6, ma& for perma to do thr Wowing �m4:
I Bwlding dimem6"
M Spme Is Fw
ba"Oeff Ckft
2. !a din�
3. rAnlding vniU b-
4. Basemau ----
5. Ocicupuvy of building wral' lv-,��6- -�—L-
6. --L?� 1.11 — feet (ROM the nearm adi-ining lLne.
7. Oxnff-WASL�-
s. Ovcm.-es Addrcs&
9.
10. ]3ufldcr s Addicss
Nmission is hcrcb� gr-Itl IP LIO the dm-ntvd bffcon. acavdinc to the appApted rlxm mW Waifiati" pe,"fift hCO3D.
subject b, comPliuxc vAlh ll� ... dim. of tbc City of &M-Wls�
PERMIT N� 661
Ef:im=cd amt S
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