21614 84TH AVE W.PDF111111111111
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21614 84TH AVE W
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9ETURN ADDRESS:
......Cit� of Edmonds, City Clerk
121 5th Avenue North
m3hds, WA 98020
01181149 3 PGS
NO&J16C04Ar 00
/NOT�CP.QF LEAITATION AND COVENANT
ADULT FAMMY HOME
oco
Referenc�--#-
Grantor(s): (2) "VVTA )4-7)V14bMk Additional on pg.—
ii Rn Qt
Legal Descriptioli (a6revii".)r. 3-0 Twn Z 7 a r "Viv
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OR' Xot Block Plat
Amessor's Tax ParceI.XWs)-,-6),,"--q9,j 000 PO 4 0 (2)
. ...... ... A:Messor's Tax Parcel ID# not yet assigned
FOR RECORDING
City of Edmonds
Page Af --ILL
WIIEREAS, the undersigned owner§ .. of pr6perty'. locaied at /41
- , I 1� ]bdMo-`nd�,"WashIngton legally described
below or on the attached Exhibit A,. hav�...aoplled. for a building permit for
compliance and/or to remodel a structure M60d on thi��lte; and
WHEREAS, the applicant has notified the City 41a0p1liant's intention to utilize the
Improvements and/or to convert an existiii�g., s I n -$ructure to an adult
family home; and . .. ....
WHEREAS, under the Uniform Building Code�., thi-.4mumb6r.-of occupants of a
structure trigger certain requirements relating to ".-p"ion and exiting
requirements; and
WHEREAS, the City has notified the applicant that'lbg, kwit'.W01 be iss, ued
conditioned on limitation of residents to 3 or fewef.' re44"ts .--iind their
caretakers; and
WHEREAS, the City has issued a permit based upon such repr6gntittigal:
NOW, THEREFORE, the undersigned property owneri (lti;d 'iMeK
I`Owneel) in consideration of the issuance of a building permit ahfl,4n-"o**rdpr-.to`.
confirm the promises upon which such Issuance Is based while provldin� notl�e:;to
any future owners or mortgagors of the property does hereby stipulati, 4��niint.
and agree as follows:
1. Covenant: Limitation an Residence. The owner hereby stipulates
and,agrees that occupancy of the structure as an adult family home shall be limited
io -3 —or fewer adults and their caretakers as allowed by applicable
p ilsions of state law. The owner acknowledges that in the event that the applicant
v
rq.
..s�k&-reylslon of the.applicant's state license to operate an adult family home with
ph occupancy of greater than 3 residents or attempts to rent, lease or
othei;6 p:rovide residence for additional residents above the
tted In the current occupancy classification, the structure shall
be oil 6sidential use ceased until such time as the property is brought
fhto-6;�6ilanc�-wl th-the provisions of the State Building Code, under the edition of
the Uh . iform *, -OuMng'. Code then In effect The owner further stipulates that this
cov�nanf'totjches add.-topcerns the land so long as the present structure and use
conti�ues.a�d "I-ju
wjj1th the land to all future purchasers and assigns.
Sd� iract. The above stipulation and promises shall apply to and
run with theland,41th-respect to a residential structure located at .2 1 1P P/ PA,*T a/
Edmonds, Washington and legally described as:
3. Notification to Future Purchase r's hi d'. Assl
. Wegs. This notification
and covenant has been recorded In the records of Snohomish County, Washington
in order to provide notice to any and all futur� o,� , q , ers"*qftbe property'of the
limitation at the current level of improvement to "Singie"famillis 'and adult family
home residents fewer than. 4 in number.
4. Enforcement. In addition to any and othe� re' les clAt or crimonni
which the City may have, the property owner hereby agf;M. -and Afl�nf�igs that this
grant of covenant shall entitle the City to enforce by Injuncdon-tlie-orovi4ous of this
code and, in so doing, to recover its reasonable attorney's feeg,'�A c
AUTHORIZED FOR RECORDING
C1!Y of Edmonds
BY: IM Date:1 �Jt_o_r
Page 7— of 75
nAlrvn 1. 12,771 A of L-e-C.'n 4M 7A 12 4c-
APPLICANUPROPERTY
ACCEPTED BY.
OWNER:
Applicant
jeannIA&IL. Grit' Xppflcant
-1056T-JUD 1� 1)oMbITA
A0=11 ;4?46� 16 7/7700 Ownei
.......... Owqr'A I
COVENANT AND
ACKNOWLEDGED:
. . ......... %
Mortgagor
NOTARY F01t qW.N_M
State of Washinktofi
County of
I certify that I know ok-AaVesatisfactefy evidence that
Signed this Instrument, on-oath.sUfed that belshe ww authorized to execute the
Instrument and acknowledgcdlit as the (title) of
(name of party on beh on4homInstrit!nent was executed) to be
the free and voluntary act of such pa-01(tor tlwfisis and.pu W ID 1111%,
instrument. Subscribed and swom-to befori� me.this _1'.3 y of
ftd6 PL#jk
state Of %wftkVWn
BEM CHAWE'rCPJjM
y Ap00%ntneM Expbras Oct 22,
M1
NotdrryPublikl�lindto'r,the.=tte.of'Washinq—, —1W1W"W1WNWW
My commission expires - ?,. -�? ,
I certify that I know or have satisfactory evidene ' e tha
signed this Instrument, on oath stated that helsh w
Instrument and acknowledged It as the.
(name of party on behalf on whom IM't
the free and voluntary act of such party for the uses 0
instrumenL Subscribed and sworn to before me this.
My' Public Inyd rR the te of
commission expif
AUTHORIZED FOR RECORDING
aty of Edmonds
By.__2�Z Dgktd2t�
Par
of I
L %T8W%BU11D1NGNF0RMS"F-00VX0C2nM4
& - Ae,4;,�v
,.dz& t� execute the
(titij) of
it wasi-ciecuted) to be
romes.mintidos In this
7
Angtq
Plohn-fubk
-.siate Of wbxhmmon
--dETTY.rmAN-rryiduiBAL
."7
ATE RECEIVED
STREET FIL.. U
ERMIT EXPIRES
CITY OF EDMONDS
PERMIT
NUMBER
CONSTRUCTION PERMIT APPLICATION
JOB
ADDRESS
SUITE/APT#
OWNER NAME/NAME OF BUSINESS
j M C. _PZ , 'P) 0 H T-) JTA
PLAT NAME/SUBDIVISION NO.
LOT NO.
I
LID NO.
W
MAILING ADDRESS
LID FEE $
AVC lb! CLO I
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TIES P:
RW PCs ll=red
13
CITY ZIP
TELEPHONF�4a6) A45 10
EXISTING PROPOSED
Street Use Perrnit Required
Inspection Required
0
13
REQUIRED DEDICATION
FT
Sidewalk Required
Underground
El
Wiring required
NAME
METER SIZE
�INE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES 0 NO C3
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ADDRESS
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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CITY ZIP
TELEPHONE
NAME
CBL#
ENGINEERING REVIEWED BY DATE
ADDRESS
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FIRE REVIEWED BY DATE
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CITY ZIP
TELEPHONE
STATE LICENSE NUMBER EXPIRATION DATE-i"
C�HECKEO:BY
VARIANCE OR CU
A
SHORELINE OR AOB#
P.
INSPECTION,.
REO'D
C3*YES ONO
SEPA
COMPLETED I EXEMP T
CA#
WAIVER
STUDY C1 I
ZONE
Lt. S
SIGN AREA
ALLOWED , PROPOSED
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HEIGHT
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ALLOWED I PRO OSED
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PROPERTY TAX ACCOUNT PARCEL NO.
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NEW �ErRESIDENTIAL PLUMBING /MECH
[3 COMMERCIAL 1:1 COMPLIANCE OR
ADDITION El MIXED USE 1:1 CHANGE OF USE
REMODEL MULTIFAMILY SIGN
GRADING FENCE
REPAIR CYDS ( X FT.)
OTHER
ri DEMOLISH TANK
ci GARAGE RETAINING WALL o F:RE SPRINKLER
CARPORT ROCKERY - F RE ALARM
LOT COVERAGE
ALLOWED PROPOSED
I N /Cl
REQUIRED SETBACKS (FT.)
FRONT SIDE REAR
PROPOSED SETBACKS (FT.)
FRONT UR - SIDE REAR
I N I oc
0z
PARKING
REQ'D PROVIDED
I N , 1
LCITAREA
1
PLANNING REVIEWED BY DATE
REMARKS
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(TYPE OF USE, BUSINESS.OR ACTIVITY) EXPLAIN:
AIDLILr FAWL &1415'
TYPE OF CONSTRUCTION
CODE
OCCUPANT
GROUP
0
NUMBER
OF .- f:
STORIES
NUMBER OF
DWELLING
UNITS
SPECIAL INSPECTION
REQUIRED C
CONSULTANT
OCCUPANT
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
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GEOTECH REPORT
BY:
STRUCTURAL DESIGN
BY:
4Mr- 6W/V &47#,8
VALUATION
(7jW111W0__r_
Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOUR7__7
LOT SLOPE77
VESTED DATE
Buildi ng Permit
City, Su rcharge
PLAN CHECK NO:
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
Grading
SEPARATE PERMISSION.
Engr. Review
Lu
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection
*APPLICANT ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND-SPCCESSORS Fi re , Review Plan Chk. Deposit
Uj INDEMNIFY, DEFEND AND HOLD HARMLESS�THE CITY, OF
j IN INTEREST, AGREES TO
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
cc Fire Inspection Receipt #
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 LandscapeInsp.
_j Total Amt. Due
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
Recording Fe Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN 15 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 permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official his/her Deputy: and Fees are paid. and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipi i�cknowledged in space provided.
WORKMEN *S5p"SATION INSURANCE AND RCW 18:27.
1 ALS SIGNAT E I DATE
SIGNATURE W IN E A�RR A 0 E�11N T) DATE SIGNED (425
07 1 A le,4'
771-0220 BY I DATEJ
AT TP N EXT. 1333
IT IS FUL TO U OR OCCUPY A BUILDING OR STRUCTUR 12-1
1 C E UNTIL
PLINISPECTIOiHIAS
A FIIN BEEN MADE AND APPROVAL OR A CERTI-
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 I IBC110 / IRC110. 0 IGINAL FI ELLOW -INSPECTOR
INK -OWfi)-GOLO - ASSESSOR
10104 %
ni5eL%L% U A nr% %/^I I A 113111� RH A Wlkl#'% A ^^n1l1fA.
Adult
OF
ZIA
SkktEEASLTH
V
7 07,
IT T,
..--Hom'e-"'..�cLicense
License Number: 717700
Pursuant to th I ax�-s f
,the W` Aiin'g"foin' a'nd;; theMi himutritip"'en' si n g,.Reauirernents
6f,`Sia -Ahd Health Servl*Ces;`.ii. h reby gr' ted to
of theDeDartment. oe Ili 1 fc' is e an
0
BLE SSED ADULT HOME. CARk;-L---LC1-,
P tornoration,represeri ed by.!-,EVITA,BOMBITA
ar ners,
jq., c6ndubt.,and maintain at 21614 84THAVE W,
Ciiy.o FED MOND`$ Zip� C6de- 98026 f NOHOMISH.'SfateofWashin&bn
ily Home for the care and-super0sion.-o f 'adults as follows:,
:an A�fflifami'
I art. adu S.
or no more
care B ih 'it'
4�hour�.
This license shall be in force1rorn'the Ist of 1)6cerriber�,-2065..�subject to su$pension orrevocati6n for Aue caus&
tion to prpv e service t s
This home has a special desipa, o persons with Illnes'
Conditions on License, if any:
A
Licensing Authority
NOTE: The department renewal of a license doe's riot pi�eclude the d6partm'e�t fro m' taking.any-a-efibn und� LC 388-76-705, based on inspection.
ip-or in i vid to whom it is issued and at the location above described.
This license is not transferable, and is valid only for use by the- "beation -partqersh' A i ua
cor-P
Issued by Author i ty o f C hap ter RCW 70.12 8 U It 0 1 N
DEC 13 2005
FINAL PROJECT APPROVAL FORM
TO:
MEMO TO:
FROM:
PIFASE SIGN
PLEA -SE SIGN
DATE:
DIVISION
E DEPARTMENT DATE t5/4//0_f
NUILN CEM11NU U1 V 131UN VA I V_
PLANNING DIVISION DATE
PROJECT 1�0'0-t 6 f 7-4 /1�
SITE ADDRESS —
PERMIT # ADB# DATEINSPECTED_ 61Iqlar'-_
DESCRIPTION OF WORK TO BE INSPECTED A=:74- 4,-z�
A field inspection was conducted to determine compliance with - approved plans. Final approval
denotes that there are no objections from the above signed Department to the release ;of
PERFO %1ANCE BONDS and the granting of:
GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
Copy of CONDITIONS given to owner/contractor by inspector
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
Copy of CORRECTION NOTICE given to owner/contractor by inpector
2
a
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Pate Signature
Ltenip:bldg: forms:ocapM 3/25/04
REQUEST FOR INSPECTION- Adult Family Home
APPUCATION NUMBER:
Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed.
SECTION 1 - PROPERTY INFORMATION
SITE ADDRESS: 94 ki ASSESSOR'S TAX/PARCEL #: 069 -MQ:x�o
lalo
PROPERTY OWNER NAME: 77639�nc 65W-bila — DAYTIME PHONE:
UCENSEE NAME (IF DIFfERW: ' DAYTIME PHONE:
SECTION 3 — FLOOR PLAN
A complete floor plan must include all sleeping rooms, identified by number (#1, #2, #3 etc.) and all components for
eAting, i.e. stairs, ramps, platform lifts and elevators. (Attach additional sheets if necessary)
SECTION 4 — DISCLAIMER/SIGNATURE BLOCK
I certify under penalty of'perjury that the information furnished by me is true and correct to the best of my knowledge, and that I am authorized by
the owner of the above premises.to request inspection for and operate an Adult Family Home at this location. I further certify that I have made
application to the Department of Social and Health Services and the jurisdiction for the appropriate license(s) to conduct such business at this
location. I furdw agree to hold harmless the jurisdiction conducting such inspections at my request as to any claim (including costs, expenses, and
attomeys'fees incurred in. -the investigation of such claim), which may be made by any person, including the undersigned, and filed against the
jurisdiction, but only where such claim arises out of the reliance of the jurisdiction, including its officers and employees, upon the accuracy of the
information supplied to the 'ction as a part f this application.
NAME/TnIE: DAME:
XPROPERTY04R-1 11 APPLIE/tff 0 UCENSEE
SECTION 5 - INSPECTION CHECKLIST
YES
NO
Home licensed (or applying for license) on or after July 1, 2001
o.
SLEEPING ROOMS
0
Sleeping Room #1 0 S 0 NSI "S2
Bedroom door is openable from the outside when locked
F(
El
Closet doors are readily openable from the inside
0
Smoke alarm is installed in the bedroom
11
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20"vvide)
0
Sleeping room window has a maximum sill height of 44"
Sleeping Room #2 tNS2
0
0 S 0 NSI
Bedroom door is openable from the outside when locked
B/
El
Closet doors are readily openable from the inside
0,
Smoke alarm is installed in the bedroom
0
Sleeping room window has a minimum net o0nable area of 5.7 sf. (minimum dimensions- 24"high; 20'vAde)
0
Sleeping room window has a maximum sill height of 44"
0
Sleeping Room #3 0 S 0 NSI N'NS2
Bedroom door is openable from the outside when locked
El
Closet doors are readily openable from the inside
El
Smoke alarm is installed in the bedroom
0
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24"high; 20"vWde)
F,
0
Sleeping room window has a maximum sill height of 44"
Sleeping Room #4 0 S 0 NSI 0 NS2
Bedroom door is openable from the outside when locked
Closet doors are readily openable from the inside
Smoke alarm is installed in the bedroom
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24"high; 20'Wde)
0
0
Sleeping room window has a maximum sill height of 44"
Sleeping Room #5 0 S 0 NSI 0 NS2
Bedroom door is openable from the outside when locked
Closet doors are readily openable from the inside
Smoke alarm is installed in the bedroom
0
0
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
0
11
Sleeping room window has a maximum sill height of 44"
0
0
Sleeping Room #6 0 S 0 NS't 0 NS2
Bedroom door is openable from the outside when locked
0
0
Closet doors are readily openable from the inside
Smoke alarm is installed in the bedroom
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24"high; 20"vvide)
0
0
Sle * eping room window has a maximum sill height of 44"
0
0
GENERAL
Bathroom doors are openable from the outside when locked
0
Smoke alarms are installed on all levels of the dwelling
C1
All smoke alarms are audible in all parts of the dwelling upon activation of a single device
Access road and water supply approved by Fire Department
V'
El
F51PASSED ECITONS REQUIRED 0 PERMIT REQUIRED
INSPECTOR: DATE: I&L
CITY OF EDMONDS
USE
ZONE PERMIT
NUMBER
CONSTRUCTION PERMIT APPLICATION
joB
ADDRESS
9 162
N
SUITE/APT
OF BUSINESS
OWNER NAME/NAME
V"I C e;J 00elg�IAR
LEGAL DESCIIIPTI"CH7ECK
SUBDIVISION NO, LID
NO.
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0
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MAIL' NG ADDI-Itbb
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TESCP
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP.
EXISTING — REQUIRED DEDICATION
Approved 13
RW Permit Required 0
Street Use Permit Req'd '0
CITY ZIP
HONENUMBER
PROPOSED Inspection
Required 0
Sidewaik Required 0
Ic
NAME
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
Uj
W
YES 0 NO 0
ADDRESS
REMARKS
L)
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CITY ZIP
TELEPHONE NUMBER
NAME
4N ii /A
ADDRESS
;2,3 �521 /�w y 017-f
c1c
0
ENGINEERING MEMO DATED REVIEWED BY
tr
I.-
Z
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CITY ZIF
EPHONE NUMBER
-77 9'
FIRE MEMO DATED REVIEWED BY
w
0
0
Lr
STATE LICENSE NUMBER f EXPIRATION DATE
07 P-5— /0/3//)l
SIGN AREA
SEPA REVIEW
ADB NO.
PROPOSED
COMPLETE EXEMPT
n
Lbgcll Description df Property - include afieas me ts
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4
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4 / �r .71
t
SHORELINE#
9
EX P
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Q.
0
C—�� N 0 el
VARIANCE OR CU
PLANNING R EVIEW BY
DATE
(n
w
SETBACKS — FEEI
HEIGHT
LOT COVERAGE
0
FRONT2,5 SIDE 7;rr_' REAR
Z
Prope Fly
REMARKS
Tax Accoun
00o
ParcelNo.,5�2?3-000—oo,/-
Fc;q EJ
NEW jtfN RESIDENTIAL PLUMBINGIMECH
COMPLIANCE OR
5?-,ADDITION
0 COMMERCIAL CHANGE OF USE
EIREMODEL APT. BLDG.
SIGN
CHECKED BY
.
TYPE OF qONSTRUCTION
1. -
:—]M=
I
OCCUPA"
GROf�
GRADING FENCE
REPAIR M CYDS. x —FT)
FIDEMOLISH WOODSTOVE SWIM POOL
INSERT HOT TUB/SPA
.
SPECIAL INSPECTOR
REQUIRED
AREA
OCCUPANT
LOAD
GARAGE RETAINING WALL/
CARPORT RENEWAL
REMARKS
ROCKERY
0
�::
PROGRESS INSPECTIONS PER LIBC 108
Z
(TYPE 0 F SE BUSINESS OR ACTIVITY) EXPLAIN:
LL
W
X 41,11
V)
LU
NUMBER
NUMBER OF
CRITICAL
0
OF
DWELLING
/7NUMBER
AREAS
W
0
STORIES
UNITS
DESCRIBE WORK TO BE DONE (ATTACH P�OT PLAN)
A E-41211
FINAL INSPECTION REWIRED
0
VALUATION
FEE
e . )05-�1019 CQkckV-Je- pedic.
01.1
PLAN CHECK FEE
BUILDING
HEAT SOURCE:
GLAZING
%
�2
PLUMBING
Plan Check No. -/C)
MECHANICAL
GRADINGIFILL
This Permit covers work to be done on private propprty ONLY.
Any construction on the public domain (curbs, sidewpiks,
STATE SURCHARGE
4,c5o
driveways, marquees, etc.) will require separate permission.
Permit Application: 180 Days
Permit Limit: 1 Year - Provided Work Is Started Within 180 Days
STORM DRAINAGE FEE
"Applicant, on behalf of his or her spouse, heirs, assigns.and
ENG. INSPECTION FEE
successors in interest, agrees to indemnify, defend and hold
20
harmless the City of Edmonds, Washington, its officials,
7.
employees, and agents from any and all claims for.damages of
4-2-1
01 U
mrr,
a:
<
whatever nature, arising directly or indirectly from the issuance
of this permit. Issuance of this permit shall not be deemed to
PLAN CHECK DEPOSIT
1
modify, waive or reduce any requirement of any city ordinance
1 - -
0
2:
nor limit in any way the City's ability to enforce any ordinance
TOTAL AMOUNT DUE
I 0
provision."
0
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 APPLICAMN APPROVAL
authorized agent of the owner. I agree, to comply With city and THIS PERMIT
state laws regulating construction; and Ip the work authoriz. AUTHORIZES This application is not a permit until
-doing
� ill be ONLY THE signed by the Building Official or his/her
ed thereby, no person w t -employtid in'violation of the Labor
Code of the State of Washington relating 116 WoAmen's Compensa- WORK NOTED Deputy; and fees are paid, and receipt is
tion Insurance and RCW 18.27. INSPECTION acknowledged In space provided.
SIGN,�T ER OR AG NT) DATE SIGNED DEPARTMENT
UT
OFFICIAL-�FSIGN 4DATYEj
CITY OF
P. ee"�� 1 —///2
EDMONDS
CALL FOR RELiA�'ED dY: 6rE
ATTINTION INSPECTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR 771-0220 'ORIbINAL — File YELLOW — Inspector
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTEO. UBC
SECTION 100 PINK — Owner GOLD — Assessor
Scale: /1,0-p �0
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STREHET FILE
APPROVED By PLANNING
— � �— —1 —,:p 0- 2—
PLANNING DATA
NAME: Vhani-
SITE ADDRESS:- Z-1 &14 44- 11ke U- —DATE: 3 Z2 -2
ZONING: PLAN CHK#: 7 - lo+
PROJECT DESCRIPTION: 4v(A
CORNERLOT NO -(Yes/No)
SETBACKS:
Required Setbacks:
Front: 2-5-' Left Side: 7�-' Right Side: 7�i' Rear: /5'
Actual Setbacks:
Front: 8z-' Left Side: 10' Right Side: / 5_' Rear: ?-0
Street map checked for additional setback required? (Yes/No)
LEGAL NONCONFORMING LAND USE DETERMINATION ISSUED (V (Y/N)
LOT COVERAGE: /70+
2-
Maximum Allowed: 3s-q —Actual: If<-4+
BUILDING HEIGHT:
Maximum Allowed: —Actual Height:
Datum Point: Ire, n� '�-d -.Datum Elevation:
A.D.U. CREATED?:
I I �__ ((eo"
SUBDIVISION:
, Mtfm --, - �-� , 10 7 (,, 0 �-
F—W
CRITICAL AREAS #: �'7 - `V9 - W,,,- vc-
SEPA DETERMINATION: r-
LOT AREA: . P44 0
OTHER:
Plan Review By:
cnl�_
CA FILE NO.
is., Checklist
77-7
WIf"VII �IIVVI 1111-W 1W 'A'.. li� 7.
.(S'0.iIg/t6 bg�dph�/,hy(:kology/vege�at�on)''�',��:"�,"
Sif6 Add -DU
�Oftu �,,DS Lu -A- -s
n:
2. Prop- T
"60- 4 t,-Fo�c66
_y, ,V Act611ht.NAiriber:;.u,F'
% - -
Si Sii' (a -7 L50
oxunate te e cres or square feet):
.4. Is this site currently developed? Y, yes; no.
If yes; how is site developed?
5. Describe the general'site topography. Check all that apply..
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: 0 6 Approx. Depth:
7. Site contaifig bf s�a_sofiai standing' water: t-3 :Approx. Depth:
What season(s� of the"*
year?.,
8. Site is in the floodwayL_&_D` floodplain K�C- of a water course.
9. Site contains a creek or an'area where water flows across the grounds surface? Flows are
year-round? LY) Flows are seasonal? 00 (What time of year?
10. Site is primarily: forested meadow
shrubs mixed
urban landscaped (lawnshrubs etc) VQ3
11. Obvious wetland is present on site: t,� 0
Am-chkdoc Pev 02/11/97
gab"
4
S
bUt
1.� r I "loi
A�
N
Mon'
-Ile
AM Uff "s,
hie
ea��
�,v
-And su mit it to the
The Critical Areas Checklist c6fitained"`.F,` b
on this form is to be. filled out by any "--',i,%fflJ rev- i6w
person preparing a Development Permit precursory site visit, and M'"ake
Application for the City of Edmonds determination of the subsequent steps
prior to his/her submittal of a necessary to complete a development -
development permit to the City. permit application.
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 Hall (Critical Areas
inventories, maps, or soil surveys), _
An applicant., or his/her representative,
must fill out the checklist, sign and date
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
nformi n g.s e'Oanfopography,
tid it
map, etc.) or studies mi`conjuncti6r�
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:
VwC,E_t,3--V _DC)Q:�aELA,4(z
Name
Applicant Representative:
Name
�,210q-SLC'AUE 3 4 3,�
, /,/t, y
Street Address Street Address
DS., qM,6 --1287q 1-5 Wk� 0 h e/ -f W4 7-7 -3d-�'6
City, Statee, ZIP Phone Oty, State, ZIP Ph on' e
3
":J"Id2L I
Signatuie , '4
Date Dater
APPLICATION
The City of Edmonds for EASEMENT NO . .. .............
SIDE SEWER PERMIT
NEW CONSTRUCTION REPAIRS 7 LID NO. ASMT. NO.
OWNER -4
---------------- ------------ -- --------- ...... --- --- ---------------------------- CONTRACTOR - ...................................... .. ........ ... ......... PERMIT NO.
----------------- ....... LEGAL DESCRIPTION: LOT NO - ----- ------ -------------- ------ BLOCK NO - -------- .. . .......... .. ..
JOB ADDRESS P . ..... --------------------
----- -------------- -- ----- --------------------------------------- ----- .................. -.- -- ------- - -----------------------------------
-A7C�� M�A V--3 L�!, P�
NAME01' ADDITION ------------------------- ----- ----------- -- ------ ---------------------------------------------------------
T
Approved:
DATE By
c --- ------- --------------
q;
"EDMOND'S" �,-`ISIIDE �`SEWER.`�'VER) M�? TTr.-'.,-
-CITY" OF I T!.
DEPARTAh&-T�', 4j"
WATEWSEWEk,
T
T. x
;--,�,,PERMITT. 11 J,
/,Call 175,M5, f6r. sldeirlseN&r6r� Inspectioni.' is k� �o it j,,; i ;cov
e r! n k,,'in Y;.., po o n of�'th�e
tk�ln'spe�tlon,'wlll'be' pro�lded', wit�hn '24' fi'o6r 8: te� iie' u'st+. pections.
a q u �611day ins
�Aveftuo,,,446s
P h
RU' .............................. .....................................................
AMDRE -�]+'6-1 k': " t
IOCkn VV6NST CTIOM� ... ............ .... ..
:'r Ad'd
�W tloh
L i . _r f'', '*
�PROPERT,Y.,'LEGA%','DES'C�RIPTION.'.-�.:...
.............................................................................................................. ............................
........... ........... � .....
.......................... ................. .....................................................................................
.....................................
Nt:,q� .;,MBBELAAR'
"O.VyWER AN,DYO'R,,BU: "-ER`�.-...: ............................
A
........................................... .. t. -
.......................................... .................
................... :.+..* ........
........................ .... ........................ ...
R!Sr,NAMK,&ADDRESS ............................. n T ................... Ain V -
U te P I bri6j: b S6w6i' 2
nj d
................... ..............................
46r;+repa r.andV6r,,conn6dti6n,�,6f.,,;i-c�idb�g�,wer,,, y�i"er,
9
Igs;stem�'inr,,ac4cord�a+nce,with-:Citv,fof,Edtriorid's ordinanceg�..�*.�
AT-14TION IS"CALLEDrM THE�,FOLLOWING:
�06,'P�;Pe'rty. may,obtain permit ito �o�struct -sewer, Inside property,line.; A licensed- Side Sewer jContracto�' rfib�t be, emplo�,e'd t'
o;-,conAtruct
�slde,.sewer,,fti,streeL area. -Do iiot,cover any portion 'of sewer before it"'has,been,,inspect6d'
N TE: No� 2—ANIP wo'r�'p'e'riorm'�d�'iii;'city,'right-.of-way. requir�s.an.'1nvaslbn-.of fionr-th City. kn�in4er�s_*6ffice.
0
NOTE, No.�,3 '�:bit�iii,f6lll.'I�fbrmation-regaxding.Ordinanc��',1.1.16.030,'ilid�'Reigulations governing,side, sewers, en. yo�: Lrmit.
"wh geV.p
.,N6TI�.�No.'4�,'T�p,.oi'.,�de-s6wer must hive at Iesst 30� inches covtr�ge, at, prqperty; line and i�.AAches insid6i' + No,)bends -in,-,jr"e,
,property, line;, ininim rn.grade�of-2%.
-sharper,than will-lb6'permitted'., +
Tre'n�lie's',in"s'tre"et-,'*m"ust',be -water'settied, and,,surface,- , of 'street restored to�oilgnai, niliiid�t�. &ntra�tor. h
NO.TE No 5-- 1 C6 s all be, responsible. for, ftflu�e!,due :to" Improper,
%vork whicho�may, develop; wlthiw,one year of completlofi.
IM�R�Nb. 'Ci--It is,-unlawfutlto. alter,or do,,any, other work thair is proVid
ed foe'ln the, perrnjt,,%or:to,do, any',,Work 6iithe+mELiii�,s6ii�er'or--its"appur enande&"except��to�jn-`
serfAhe,�pipc ffito,:the wye�;,.
By ................
..................
a e ..... .. ; . . .... ........
DISAPPROVE,W �Ej' D t .............. By . .. ...... Date'
NPPROV
D . .. .. .... ...........................................................
. ................. ......... ...... ....... ..
Reinai .................................... .........
Z., ........................... .......
............... ......
....... 0000,��� ..................... ...............
................ ................ ................ .......
............................................. ........................ ........ ..... .... ............. K ..........................................................
7BOT*H."-,Pbl-lyiit�",Cijp�ies'.MU."STBe,Signdd-ljy-ow�br--��i,,�ii,rm�performing,,6'o'-s"f..,r,,u,c-tiori��- ties IFor'inspect.fbn1
n PRIONT6,'Req --t"'
i iaiio',;
hereby cer4fry th�f,A-he*Sidb,.seW.'6r ins n cons trW�ted,sund�r:ithi . s, Perini
...... 7C.-
c, of,
(Owner of' OntrActing. Firm PerfGrmlng� Cons ructloh,5;
.7 %
y �0 ......
J Dat�&,this ........ W
19'
........... 7: ....... . . ...............
or:, E)", Cva8,;E],' Telephofieit,�,, bwer"' 'e',b th e'r_1,['j
;&6ck BEFORE youdig, f W, "a' le, r, S
7.,
APPLICATION
for
.The City of Edmonds SEDE SEWER PERNaT EASEMENT No . ...............................
NEW CONSTRUCTION 0 REPAIRS 0
4 11) )qA
PERMIT No...":/�70 ....
OWNER ... ................. CONTRACTOR
ADDRESS - ------ ?J/ .. ......... ................. ................. LEGAL DESCRIPTION: LOT No - --------- �/ ............................... BLOCK No . ............................................
NAME OF ADDITION ........ All-im-k .........
. . ......................................
0
0
0
Approved:
RECEIVE-L,
MAy 2 3 1974
DATE ..............
.............. By ......................................................................
F-1
L -�
RETURN ADDRESS:
City of.Edmonds, City Clerk
121 5th Avenue'North
Edmonds, WA 98020
CONFORMED COPY
2�0601181149 3 PGS
0 012006 4:25r
, N4,00
SNOH MISH COUNT ASHINGTON
NOTICE OF LIM. ITATION AND COVENANT,
ADULT FANHLY HOME.'
Reference #:
Grantor(s): (1) -10519-F-VMO "?J0 (2) 1XWrA H-104b0-A- Additional on pg._
Grantee(s): Cit of Edmonds
Legal Description (abbreviatedi: Sec 3-0 Twn 4?7—Rn Qtr NAV
OR Lot Block 'Plat —
Assessor's Tax Parcel ED#(s): (1) i��OJ 000 *00 q 0 0 (2)
Assessor's Tax Parcel ED# not yet, assigned
AUTHORIZED FOR RECORDING
City of Edmonds
By:. --7Z6 -Z Date%ZLt3-0-s-
Page *- -of -3- 1
WHEREAS, the undersigned owners of property located at
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 trisuzer certain requirements relating to the fire suppression and exiting
requirement�-,and
WHEREAS, the City has notified the avvlicant that the pe rmit I w I I I ' be"'is'siu e a'
conditioned on liudtation of residents to or fewer residents and their
caretakers; and
WHEREAS, the City. has issued a permitb.ased upon such representations;
NOW,. THEREFORE, the undersigned property owners (hereinafter
11owner") 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 structu rie as an adult fandly home shall be limited
to —3 or fewer adults and, their caretakers as allowed by applicable
provisions of state I ' aw. 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 qccupancy.of greater.than -3. residents or attempts to rent, lease or
otherwise- provide residence for additional residents above the
3 pern-dtted. 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 tode-then in effect. The ownerfurther 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.
SuIxiect Tract The above stipulation and pron-dses shall apply to and
2.
run with the land with respect to a residential structure located at 1P Aor u)
Edmonds, Washington and legally described as:
.3. Notification to Future Purchasers and Ami2nees. 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 p roperty of, the
famil n
limitation, at' he-! current level- of *ro�ement'to single les a d adult family
hoine'residents fewer than 4.1 in number.
.4. Enforcement. In addition to any and other remedies civil orcriminal
which the City may have, the property owner hereby agrees and stipulates that -this
grant of covenant shall entitle the City to enforce by Injunctionthe provisions of this
code and, in so doing, to recover its reasonable attorney's fees and costs.
AUTHORIZED FOR RECORDING
. City of Edmonds
B . y: 6- Date: 12-Y.7—os-
page Z_ of 3
DATED this 7?1 day of IC7�6eyn /,ILM 20 0-5-
ACCEPTED BY:
OWNER:
Jeannine L. Graf
Building Official
A"CH 1-14e.'VOC6 .7/-7vo
A�60/,r #,a0aS--0&5-V
NOTIFICATION
NOTARY FOR OWNER SIGNATURES
State of Washington.
)ss
County of
APPLICANTAPROPERTY
L�vrTA H, -tooj-rA
Applicant
Applicant
1056T-jo �,,
Ownei
Otr
COVENANT AND
ACKNOWLEDGED:
Mortgagor
I certify that I know or have satisfactory evidence that a�yh
signed this instrument, on . oath stated that he/she was authorized to execute the
instrument and acknowledged lit as the 42,ee��e , (title) of
(name of party on behalf oii whom instrument was.executed) to be
the free and voluntary act of such party for the uses and puFpo Alentions in tbis_
instrument. Subscribed and sworn to before me this 43 e ay of
State of WVMhhWiW
&.1
the
My commission expires__LK-C41-
of W
BETTY CHAWEYI
My Appointment Expires
I certify that I know or have satisfactory evidence that �Z�46 le,
signed this instrument, on oath stated that h thorizi6d to.execute the
instrument and acknowledged it as the ' (title) of
(name of party on behalf on whom instrument was executed) to be
the tree and voluntary act of such party for the uses and purposes mentions in this
Instrument. Subscribed and sworn to before me this A3.t day of SLA44
2 406' LJ
4 Public it
commission
of W
AUTHORIZED FOR RECORDING
City of Edmon&
By: '7Z� Date:/2-070S_
Page of 3
L-\TFZ*U)\BULMING\FORNLSkADF�-COV.DOCV10/04
Notary Public
Stile of Washington.
BETTY CHAN-ETOUl"t
My -Appointment Expires Oct 22,