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TAXACCOUNT/PARCELM
BUILDING PERMIT (NEW STRUCTURE)
COVENANTS (RECORDED) FOR:
CRITICALAREAS#: DETERMINATION: Conditional Waiver []StudyRequired �Waiver
CRITICAL AREAS #: DETERMINATION: Conditional Waiver El Study Required F] Waiver
DISCRETIONARY PERMIT #'S:
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORD FOR:
PERMITS (OTHER — list permit #'s):
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED:
SEWER LID FEE $:
LID #:
SHORT PLAT FILE:
LOT: ::T�LOCK-
SIDE SEWER AS BUILT DATED:
SIDE S EWERPERMIT(S)#:
GEOTECH REPORT DATED:
STREET USEIENCROACHMENT PERMIT #:
FOR:
WATER METER TAP CARD DATED:
OTHER:
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CITY OF EDMONDS
BVILDING DEPARTMENT
WORK �* e d / (lq.4- gew - I
ADDRESS
OWNER ��r
77 - QQk- V\
APPROVED DATE:
BLDG. OFFICIAL
PER�4!T NUMBER
W 3-6 �? I
ZONE--&_g
SETBACKS:
FRONT
SIDE -7�&P
REAR---L-!E�
OTHER
HEIGHT
*AE D PN41 N
97 U13C
RECEIVE:r)
JUN 10 12,99
DEVELOPMENT SEfjVICES CT
CITY OF EDMONDS R
1p C. 18 ()"1
0 0
BARBARA FAHEY
CITY OF EDMONDS MAYOR
121 5TH AVENUE NORTH - EDMONDS, WA 98020 - (425) 771-0220 - FAX (425) 771-0221
DEVELOPMENT SERVICES DEPARTMENT
Planning - Building - Engineering RECEIVED
JUN 0 8 1999
May 27, 1999 DEVELOPMENT SERVICES CTR.
CITY OF EDMONDS
Robert M. Sloan
2170584 th Avenue W
Edmonds, WA 98026-9718
Subject: Determination regarding Critical Areas Checklist# 99-139
Dear Applicant: I
Enclosed please find a copy of the Critical Areas Checklist you submitted. The "DETERMINATION" reached by the City
is located on the reverse side of the form (bottom of page).
It is very important for you to retain a copy of this Critical Areas Checklist "DETERMINATION" for your records.
IMPORTANT INFORMATION TO BE NOTED:
PLEASE EXAMINE THIS" DETERMINATION" FOR ADDITIONAL REQUIREMENTS. YOU MAY NEED TO SUBMIT
ADDITIONAL INFORMATION SUCH AS AN ENWRONMENTAL CHECKLIS OR CRITICAL AREAS STUDY,
'The IdEtERMINATION' for the Critical Areas Checklist you submitted is a site -specific determination not a
projqct.-Specific determination.
mo, -You must submit a cony of the CRITICAL AREAS CHECKLIST and DETERMINATION MTH ALL AN
PERMIT APPLICATIONS or YOUR APPLICATION WILL NOT BE PROCESSED.
Permit applications include the following:
Building Permits
Conditional Use Permits
Subdivisions
Variances
Applications to the ADB* Land Use Applications
Any other development permit applications.
Incorporated August 11, 1890
Sister City - Hekinan, Japan
E No'
c
Critical Areas Checklist
---------------- ---------------------------------------------
Site Information (soil s/topography/hydrolo gy/vegetation)
1. Site Address/Location:
2. Property Tax Account Number: ��o2-i rj41 oi5 or,
3. Approximate Site Size (acres or square feet): 6 `� �� 0`20
4. Is this site currently developed? �� yes-, no.
If yes; how is site developed? h�,ec RFIECEIvED
5. Describe the general site topography. Check all that apply. JUN
Flat: less than 5-feet elevation change over entire site. WMO�!�T SERMES CM-
VXV Of EDWOM
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
I 0-feet over a horizontal distance of 3 3 to 66-feet).
Steep: grades of greater than 3 0% present on site (a vertical rise of I 0-feet over a
horizontal distance of less than 33-feet).
Other (please describe):
6. Site contains areas of year-round standing water: fkLO Approx. Depth:
7. Site contains areas of seasonal standing water: A10 _;Approx. Depth: _
What season(s) of the year?
8. Site is in the floodway J 0 floodplain_ of a water course.
Z,
Site contains a creek or an area where water flows across the grounds surface? Flows are year-
round? �,-j 0 Flows are� seasonal? _ (What time of year?
10. Site is primarily: forested meadow ;shrubs mixed
urban landscaped (lawn,shrubs etc)
11. Obvious wetland is present on site:
DMIMINATION
%3-chk.doc; R� 10103/97
0
City of Edmonds
"k1W CRITICAL AREAS CHECKLIST
The Critical'A� ' eas Checklist contained on this fon-n is
to be filled out by any person preparing a
Development , Permit -A pli ation for the City of
p ic
Edmonds prior to his/her submittal of a development
permit to the City.
The purpose of the Checklist is to enable City staff to
determine whether any potential Critical Areas are, 'or
may be, present on the subject property. The
information needed to complete the Checklist should
be easily available from observations of the site or
data available at City Hall (Critical Areas inventories,
maps, or soil surveys).
RF—CrVVED
MAY 1 '17 1999
pLAjjj,.i;1-'6-Li DEPT.
An applicant, or his/her representative, must fill out
the checklist, sign and date it, and submit it to the
City. The City will review the checklist, make a
precursory site visit, and make a determination of the
subsequent steps necessary to complete a development
permit application.
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 pertinent information (e.g., site plan, topography
map, etc.) or studies in conjunction with this Checklist
to assist staff in completing their preliminary
assessment of the site
I have completed the attached Critical Areas Checklist and attest that the answers provided are factual, to the
best of my knowledge (fill out the appropriate column below).
Owner/Applicant:
Name
Street Address
city State Zip
111-25— 6 �� 1? 3 z ;72
Telephone
Signature
5-11,219 5�'
Applicant Representative:
Name
Street Address
City State
Telephone
Signature
Zip
N
F
Date
Date
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Critical Areas Checklist
--------------------------------------------------------------
Site Information (soil s/topo graphy/hydrol o gy/vegetati on)
1. Site Address/Location: '20 D
2. Property Tax Account Number: — �,�02�1 r241 015 00
3. Approximate Site Size (acres or square feet): 6--1-0 ,
4. Is this site currently developed? yes; no.
If yes; how is site developed? /,-' 6 (- 1_�4 "I / Z_
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 I 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
I 0-feet over a horizontal distance of 3' ) 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: ALO Approx. Depth:
7. Site contains areas of seasonal standing water: A10 Approx. Depth:
What season(s) of the year?
8. Site is in the floodway J 0 floodplain_ of a water course.
9. Site contains a creek or an area where water flows across the grounds surface? Flows are year-
round? Flows are� seasonal? (What time of year?
10. Site is primarily: forested meadow shrubs mixed
urban landscaped (lawn,shrubs etc) I
11. Obvious wetland is present on site: /-)D
.3. :Weiland:ihv'.tnt*or...v�orC.:A..�ma.p.:in*ditateswet:landprps�jlt,pn.si.te?.,..
- ic'M Areas. inventory or C.A. map: indicaies.Critical Area on. site?
5.;. Site. w'ithin,desigtated earth-suWdence landslide hazard.:area.?
6 �Site- . d . 6� . igndted:*o:n.ih.e:�Ehvitbhmentally... Sensitive Areas, Map?.Lj
DMRMINATION
�c2_chk.doc� Rev 10/03/97
City of Edmonds
CRITICAL AREAS CHECKLIST
The Critical Areas Checklist contained on this form is
to be filled out by any person preparing a
Development Permit Application for the City of
Edmonds prior to his/her submittal of a development
permit to the Citv.
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).
RF—CEIVED
MAY 1 7
pLAWj,�il;-16-6 DEPT.
An applicant, or his/her representative, must fill out
the checklist, sign and date it, and submit it to the
City. The City will review the checklist, make a
precursory site visit, and make a determination of the
subsequent steps necessary to complete a development
permit application.
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 pertinent information (e.g., site plan, topography
map, etc.) or studies in conjunction with this Checklist
to assist staff in completing their preliminary
assessment of the site
I have completed the attached Critical Areas Checklist and attest that the answers provided are factual, to the
best of my knowledge (fill out the appropriate column below).
Owner/Applicant: Applicant Representative:
A SLO�I-J
Name
e �/ -7-e!Le
Z 170-'--) _ t4'
Street Address
City Srtate Zip
,�42 5— 6 �� '7 _3 4 /7 2
Telephone
Signature
5-11,;?19 5�'
Name
Street Address
city State Zip
Telephone
Signature
Date
Date
c:reception\jana\cac1.doc (over)
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e-01,- -
CITY OF EDMONDS
121 5TH AVENUE NORTH - EDMONDS, WA 98020 - (425) 771-0220 - FAX (425) 771-0221
DEVELOPMENT SERVICES DEPARTMENT
Planning - Building - Engineering
C. S9
May 27, 1999
Robert M. Sloan
2170584 th Avenue W
Edmonds, WA 98026-9718
Subject: Determination regarding Critical Areas Checklist # 99-139
Dear Applicant:
BARBARA FAHEY
MAYOR
Enclosed please find a copy of the Critical Areas Checklist you submitted. The "DETERMINATION" reached by the City
is located on the reverse side of the form (bottom of page).
mo, You must submit a copy of the CRITICAL AREAS CHECKLIST and DETERMINATION WITH ALL .40
PERMIT APPLICATIONS or YOUR APPLICATION WILL NOT BE PROCESSED.
Permit applications include the following:
Enc: Determination
* Architectural Design Board
C:Reception\Jana\CRLTR.doc
Building Permits
Conditional Use Permits
Subdivisions
Variances
Applications to the ADB* Land Use Applications
Any other development permit applications.
Thank you.
Planning Secretary
Incorporated August 11, 1890
Sister City - Hekinan, Japan
ILENO. q01_1Sq
C*ritical Areas Checklist*
--------------------------------------------------------------
Site Information (soils/topo2raphy/hydrolocy/vegetation)
1. Site Address/Location: �20 D
2. Property Tax Account Number: so2_i o4l ots oo
3. Approximate Site Size (acres or square feet): '7 6
4. Is this site currently developed? P/"- 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 I 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 3 M present on site (a vertical rise of I 0-feet over a
C)
horizontal distance of less than 33-feet).
Other (please describe):
6. Site contains areas of year-round standing water: A10
..._; Approx. Depth:
7. Site contains areas of seasonal standing water: A/0 _; Approx. Depth. -
What season(s) of the year?
8. Site is in the floodway J 0 floodplain of a water course.
9. Site contains a creek or an area where water flows across the grounds surface? Flows are year-
round? _j 0 Flows are� seasonal? (What time of year?
10. Site is primarily: forested meadow shrubs mixed
urban landscaped (lawn,shrubs etc)
11. Obvious wetland is present on site: /0
- ---------- ----------- - -- - - -------- -- - -- -- -- :For City Staff.:Use:On -------- ---------- ... ....
Site. is 2.66e&:
DETERMINAT.16N
lu_chk.dc,c� R� 1MR97
0
City of Edmonds
NTW -CRITICAL AREAS CHECKLIST
The Critical Areas Checklist contained on this form is
to be filled out by any person preparing a
Development Permit Application for the City of
Edmonds prior to his/her submittal of a development
permit to the Citv.
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).
RECEIVFM
MAY 1 7 1999
,W DEPT.
PLANV6'
An applicant, or his/her representative, must fill out
the checklist, sign and date it, and submit it to the
City. The City will review the checklist, make a
precursory site visit, and make a d6termination of the
subsequent steps necessary to complete a development
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 pertinent information (e.g., site plan, topography
map, etc.) or studies in conjunction with this Checklist
to assist staff in completing their preliminary
assessment of the site
I have completed the attached Critical Areas Checklist and attest that the answers provided are factual, to the
best of my knowledge (fill out the appropriate column below).
1.
Owner/Applicant:
Name
Street Address
Applicant Representative:
Name
Street Address
city S�tate Zip City State
'�42 r 6 �� /-? 3 Z
Telephone
��� 'I-W,
Signature
5-11,-219r
Date
Telephone
Signature
Date
Zip
(over)
creception\janakacl.doc
11
APPUCATION
Ae City of Edmonds for EASEMENT NO - --------------- --------------------
SIDE SEWER PERMff
LT Fn-jt
REV CONSTRUCTION REPAIRS LID NO. _ASMT. NO.
OWNER ------------ CONTRACTOR- _71
---------------------- .......................... ........... ------------------_--- PERMIT NO . ...............
JOB ADDRESS
LEGAUDESCRIPTION: LOT NO - ----- -------- - -------_----_---- - BLOCK- NO - --------------------------------------
--------------------------------
..................................................................................................................................................................
NAME OF ADDITION ..... . .......
Approved:
DATE ----------- By
,/,eg!jjjj;;j 0 -------------- ---_--------_---
APPUCATION
The 'City of Edmonds for EASEMENT NO. -- ---------------------------------------
SIDE SEVM PERMff
NEW CONSTRUCTION 0 REPAIRS 0 LID NO - ---------------- - -AST%4T. No - ------------------
OWNER --- - --------------------------------------------------- CONTRACTOR ..... PERMIT NO.
JOB ADDRESS ------------------------------ LEGAL DESCRIPTION: LOT NO - -------------------------------------- BLOCK NO - -------------------- ...............
--------------------- -------- --------- ............... -------------------------------------------- ----------------------------------- ------------------------
NAMEOF ADDITION ------------------------------------------------------ ----------------------------------------------------------------
,--�>lv
Approved:
DATE------------------------------------------- � By ------------------------------------------------
CITY OF EDMONDS SIDE SEWER PERMIT
WATER -SEWER DEPARTMENT
PERMIT U, 6
Call 775-2525 for side sewer Inspections, BEFORE covering any portion of the con tructi
Inspection will be provided within 24 hours after reclust. NO Sat., Sun., or holiday In s'�pectloon)
................... ... .....
ADDRESS LOCATION OF CONSTRUCTION ......... -A.... ....................................... ....... .. . ...........................................
PROPERTY LEGAL DESCRIPTION ........... ...... �:� ............... ..............................................................................................................
I
................................... ............................................................................ : .................. ( .................. .......................................... ............................................................
......................................................... OWNER AND/OR BUILDER .... ...... ............ .� .......................................................
WN'TRACTOR'S NAME; & ADDRESS ..........
............................ . ..................................................................................................
for repair and/or connection of a side sewer to the city sanitary sewer
Permission Is granted . .......... ...........
sy-tem in accordance with City of Edmonds ordinances.
A'1-�ENTWN IS CALLED TO THE FOLLOWING:
NOTE No. I —The owners of the property may obtain a permit to construct sewer Inside property llne� A licensed Side Sewer Contractor must be employed to construct
side sewer In street axea. Do not cover any portion of sewer before It has been Inspected.
NOTE No. 2—All work performed In city right-of-way requiresan Invasion of Right -of -Way Permit obtainable from the City Engineer's office.
NOTE No. 3—Obtain full Information regarding Ordinance 11.16.030 and Regulations governing side sewers when you get permit.
NOTE No; 4—Top of side sewer must have at least 30 inches coverage at property line and 12 inches Inside property line; minimum grade of 20/0. No bends in grade
sharper than 'A will be permitted.
NOTE No. 5—Trenches In street must be water settled, and surface of street restored to original condition. Contractors shall be responsible for failure due to Improper
work which may develop within one year of completion.
NOTE No. 6--It is unlawful to alter or do any other work than is provided for in the permit, or to do any work on. the main sewer or its appurtenances except to in-
sert the pipe into the wye.
DISAPPROVEDE] Date .......... By ................ Date ..... ...... By ................ Date .................................... 'BY ................
APPROVED Date ... 25 ............. By ...... ...... . .. . ............................... .......................................................
..........
Remarks: .................................... .......................................................................... ............................................................................................................
BOT"ermit Copies MUST Be Signed By Owner of Firm Performing Construction PRIOR To Request For Inspection —
hereby certify that the side sewer - installation constructed under this permit
'(Owner
of Cont'. Ing' Construction)
wiw-instalIed in accordance with all -governing ordinances of the City of Edmonds.
Dat ed this ..... 1-A ................. (lay of .... ..................................... 1 19 .........
Check BEFORE you dig for: Water Gas, Telephone Power E], Sewer E], Other E]
M
U-0
43,
4k
Water Service Drawing
The City of Edmonds EASEMENT NO . ............................................
NEW CONMUCTION 0 REPAIRS C9 LID NO . .................. . ASMT. NO . ..................
OWNER .......................................................................................... ..................... PERMIT NO.
...... CONTRACTOR
JOB ADDRESS ..'F?)765- 2AI+j�A-41-- W I I
..................................................... ................ LEGAL DESCRIPTION: LOT.NO . ...................................... BLOCK NO . ....................................
...................................................................................................................................................................
NAMEOF ADDITION ............................................. i ..........................................................................
I
11
Approved:
DATE ... S.-31— 7? ............... By A., C'54,lit .../
............. ...................... !C.4s . . .................
-0001-11175 (REV. 11/78)
PWW
NOTICE:
Nb -wa-�ra—h-ty-0-t-a-c-C-01--r-a-c-Y.-
The mformation'shown on the attached
map(s) was compiled for use by the City Of
Edmonds., its Employees and Cons'ultants.
Th,e City of �Edm.qnds does not . wa rra nt the
accuracy of anything set forth on t hese
rnap(�_). Any person or entity -requesting a
copy should conduct an Independent
ation shown on
inquiry regarding the inform
including, but not limited to,
-t-Fe -m a p (s)
b shown. Such
the location of any sewer stu
sewer stubs may or may, not exist and may
or may not exist at the location shown.
Neither the ,-;ty of Edmo-nds nor its
k_1 I
emp,to,yee's o'r office-rs -sh-a-11 be l-`1a-b-1`e for the
i n
information give on this map(s), nor for
tation provided based
any one represen
upon . said map(s).
I*
REGARDING: 21705 - 84th Avenue West 41.? 4- 6 76�5,?
(address)
R E C 0 R D 0 F C 0 N T A C T S
NAME PHONE NO
DATE . I
ADDRESS of CALLER
7/17/75 Daniel Swanson
7/21/75
8/5/75
9/16/75
9/16/75
W, r WIT 14 "W
Certified Letter No. 406675 sent
requiring hook-up within 60 days.
Mr. Swanson called as to when the
sewer lines were installed.
Mr. Murry from FHA called. Tried
to determine whether or not FHA would
have to pay for installation.
Lynnwood Sewer came into office and
obtained permit #S307.
-Counection cm—pleted.—
ACTION TAKEN
Letter received.
INITIALS
JT
JT
Called again and said FHA will be JT
responsible for the installation.
However., an extension may be required.
JT
JT
No. 406675
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PERMIT EXPIRES LILL LZ
CITY OF EDMONDS
us PERMIT
ZONE
NUMBER 99(P363-
CONSTRUCTION PERMIT APPLICATION
JOB SUITE/APT#
ADDRESS 0 L_
OWNER NAME/NAME OF BUSINESS
Aor 0A.
I& 7,cjf r
LEGAL DESCRIPTION CHECK
SUdDIVISION NO.
LID NO.
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MAILING ADDRESS
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved 0
CITY
ZIP
TELEPHONE
EXISTING — REQUIRED DEDICATION _
RW Permit Required 0
Street Use Permit Req'd 0
PROPOSED
Inspection Required 0
_7E
Sidewalk Required 0
NAME'
METER SIZE
SIZE
NO, OF FIXTURES
PRV REQUIRED
uj
YES 0 NO 0
3
I.-
ADDRESS
REMARKS
W
2
cc
4
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CITY ZIP
NE
NAME
... - ��L ,0- �., C'0 .1) fred C_ 7-1,1
ENGINEERING MEMO DATED REVIEWED BY
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ADDRESS
4
M
WAY% eA )i
FIRE MEMO DATED REVIEWED BY
ILI
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z
0
CITY ZIF:f
TELEPHONE
M
VARIANCE 08 CU
ADBN
SHORELINE #
NUMBER EXPIRATION DATE _7CKED
BY
-----------------
SEPA REVIEW
COMPLETE EXEMPT
SIGN AREA
ALLOWED PROPOSED
HEIGHT
ALLOWED PROPOSED
z
0
LEGAL DESCRIFTION OF PRCIVERTY - INCLUDE ALL EASEMENTS
EXP
W
LOT COVERAGE
ALLOWED
REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (FT.)
PROPOSED
FRONT SIDE REAR
FRONT URSIDE REAR
PROPERTY TAX ACCOUNT PARCEL No.
0
Lu
_j
-1 OP 2191V 0/ 5 — 0000
LOT AREA
REVIEW BY D
z
V1
NEW RESIDENTIAL C:1 PLUMBING MECH
A-
REMARKS
F-1 ADDITION 0 COMMERCIAL 0 COMPLIANCE OR
rr
CHANGE OF USE
REMODEL 0 APAR TMENT 0 SIGN
REPAIR 0 - GRADING CYDS FENCE.
CHECKEDBY fTY"-0)F_CSTR7CTION
CODE
OCCUPANT
X FT)
DiMOLIS11
0 TANK 0 OTHER
__V_ A
GROUP
A,;>-
z
GARAGE"
CARP04T 0 RETAINING WALL 0 RENEWAL
RQCKEAY*
SPECIAL INSP
REQUIRED ECTCR 14—REA— OCCUPANT
0 YES LOAD
/c5,r
L(415
P
us
(TYPE OF USF, 8 INESS OR ACTIVITY) EXPLAIN:
REMARKS
0
(n
PROGRESS INSPECTIONS PER UBC 108
3
W
0
NUMBER I NOMBER OF I
OF �
0
o
DWELLING . JCRITICAIL
AREAS
I
STORIES UNITS NUMBER
4k. 1-3U k�a_j ;7jd)4a4
DESCRIBE %YORK TO BE DON
0,
Or _5,6�6_,a (
INAL:INSPECTION'RIEQUIkED
IV-SO'k
VALUATION
FEE
Vo. Uzi
PLAN. CHECK FEE
HEAT SOURCE
GLAZING %
LOT SLOPE %
-
BUILDING
PLAN CHECK NO:
�-42
VESTED DATE
PLUMBING
THIS PERMITAUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
MECHANICAL
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBILIC
:I
DOMAIN (CURBS.SIDEWALKS, DRIVEWAYS. MAROUEES,ETC.) WILL REQUIRE
GRADING/FILL
SEPARATE PERMISSION.
STATE SURCHARGE
W
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT' I YEAR - PROVIDED WORK IS STARTED WITHIN 160 DAYS
STORM DRAINAGE FEES
U)
W
.j
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESORS
ENG. INSPECTION FEE
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 WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY
_j
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF TH IS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
ou
hmv,
0
DEEMED TO MODIFY. WAIVE OR REDUCEANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT
IN ANY WAYTHE CITY'SABILITYTO ENFORCE ANYORDINANCE PROVISION.'
AMOUNT DUE
TOTAL
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
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-
APPLICATION APPROVAL
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF
CALL This application is not a permit until signed by the
WASHINGTON
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27. RELATING TO
FOR
Building Official or his/her Deputy; and Fees are paid. and
INSPECTION
receipt is acknowledged in space provided.
sl QUATIJAI (OWN RAG T
WS�3E
DATE SIGNED
OF I
425) S URE PATE
14:19 �* .
771-0220
ATTENTION
REL TSED B�, DATE
IT IS UNLAWFUL TO USE 08 OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HASBEENMADEANDAPPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HASBEENGRANTED. UBC SECTION 109
ORIGINAL - FILE YELLOW - INSPECTOR
5!98
PINK -OWNER GOL D - ASSESSOR