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Critical Areas Checklist
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11A I
City of Edmonds PERMIT NO:
"U101k41rrr vxriDyl
SIDE SEWER PERMIT
Property Tax Account Parcel N
Attach copies of all access and utility easements N114 Verifie� and Approved b
A/w 7kq
il /
�VA)
Owner and/or Contractor:
Contractor License #: t- V Building Permit.#:
E] Single Family Invasion into City'*Right-of Way:. E] Yes 'R No
F� Multi -Family (No. of Units *RW Construction Permit
Fq�`C'ommercial (No. of Units Cross other P rivate..,P rope rty: E] Yes 2 No
F1 Public "Attach legal descriptiofi and copy of recorded easement.
Owner/Contractor
Owner or `contr"� signature a;Kd' acknowledgement statement: Date
B signing for this permit I certify that I have read the City's public handout entitled
g, Y I
IwSide Sewer Specifications, and shall comply with all City requirements outlined therein...
2 CALL DIAL -A -DIG (1-800-4211�5555) BEFORE ANY EXCAVATION 9
.9 FOR INSPECTION CALL 425-771-0220 extensiony'-3-.2-6-j-'
24 HOUR NOTICE REQUIRED FOR ALL INSPECTION REOUESTS
1�_
NOTE: IF JOB SITE IS NOT READY FOR INSPECTION WHEN
.INSPECTOR ARRIVES A $45 RE -INSPECTION FEE WILL BE CHARGED,'
Job Site Ready YES NO —Date: Initial:
Partial Inspection: Date:— Initial:
Partial Inspection: Date: Initial:
FINAL INSPECTION APPROVED: Date: 10V-Z 3A23 Initial�� As -built to Street File:
t� PERMIT MUST BE POSTED ON JOB SITE t�
WhiteCopy: File -Green Copy:, Inspector Buff Copy: Applicant
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CITY OF EDMONDS SIDE SEWER AS -BUILT
ADDRESS
22625 HWY 99
PERMIT
NUMBER 9522
H . OMEOWNER xxxxxxxxxx
CONTRACTOR xxxxxx
DATE
08/03/01
DRAWN ISMAEL ABILA
BY
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(174Q SNOHOMISH
HEALTH
DISTRICT
June 18, 2001
Linda Hodgins
Licensing Representative
Circle K Stores, Inc.
PO Box 52085, DC-36
Phoenix, AZ 85072-2085
ENVIRONMENTAL HEALTH DIVISION
3020 Rucker Avenue, Suite 104
Everett, WA 98201-3900
425.339.5250 FAX: 425.339.5254
Healthy Lifestyles, Healthy Communities
2�9 40
OP
,eo' 4�
�P41,
%Zee*"
Subject: Change of Ownership — Circle K # 5927 (formerly U-Save Mini Mart), 22625 Hwy 99,
Edmonds, Washington
Dear Ms. Hodgins:
The Snohomish Health District has received your application for operating permit for Circle K
#5927, (formerly U- Save Mini Mart) at 22625 Hwy 99, Edmonds, Washington.
Your application is for a grocery and deli. Health District records indicate that this facility does not
have a deli. This facility has been licensed only as 'a limited grocery. Prior to permit issuance and
operation of the deli, plans and specifications for the deli, a plan review application, plan review fee
and a copy of the proposed menu must be submitted to the Snohomish Health District.
Please note that prior to opening of the deli facility, after the Health District plan review process is
0
completed and construction is finished a preoperational inspection must be conducted.
If you:h;ave �a questions, please co ct me at 425.339.5250.
Sincer
�ob-ert Hoppa,
Environmental Hea Specialist
RH/sm
cc: City of Edmonds Building Department
Everett Office Washington State Liquor Control Board
Steve Wentzel, Store Manager
David Compton, RS, Environmental Health Specialist
Enclosures: Plan Review Construction Guidelines
Plan review application
Fee Schedule
PA!
CITY OF EDMONDS
Permit No. �i_ 144 -
Z
0
W
U
C4
0
U.
COMMUNITY SERVICES DEPARTMENT IVIA 1 9 1991
RIGHT-OF-WAY CONSTRUCTION PERMIT
A. & Owner: Washington Natural Gas Company B. 0 Contractor:
Name
815 Mercer Street tST49-T
lailintPddress
,2
eat e WA 98111
City State Zip
C. 9 Address or Vicinity of Construction: 22625 Highw
Type of Work to be Done: Install New Service
Issue Date S - ") -, � �
Name .
Mailing Address
City State Zip
State License Number
99
D. 0 Work inConnection With: 0 Sub or Plat 0 Single Family 0 City Projects
0 Commercial 0 Multifamily EN Utility
E. 0 Pavement Cut: JR Y D N F. 0 Size of Cut: 2 x 4 (1) @ Gas
Number
APPLICANT TO READ AND SIGN
INDEMNITY: Applicant understands and by his signature to this application, agrees to hold the City of Edmonds
harmless from any injuries, damages, or claims.of any kind or description whatsoever, forseen or unforseen, that may
- �ar ments or employees, including or not limited to the defense
be made against the City of Edmonds, or any of de t
of any legal proceedings including defense costs, Zurt/cost&_-a &ayr7ey fees by reason of granting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR QRKMANSHIP AND MATERIALS FOR A PERIOD OF ONE
YEAR FOLLOWING THE FINAL INSPECTION AND ACCEPTANCE OF THE WORK.
Estimated restoration fees will be held until the final street patch is completed by City forces, at which time a debit or credit will be
pr ocessed for issuance to the applicant.
• A 24 hour notice is required for inspection; Pleas ' e call Engineer ' ing: 771-3202
• Work is to be inspected during progress and at completion.
• Restoration to be in accordance with City Code.
• Street to be kept clean at all times.
• Traffic Control to be in accordance with City regulations.
• All street -cut ditches must be patched with asphalt or City approved material prior to end of working day;
NO EXCEPTIONS.
I understand the above and that this permit must be available at the job site for inspection purposes at all times.
Signature
Date: May 1, 1991
Owner or Contractor
This Permit Must be Posted at the Job Site For Inspection Purposes
Call DIAL -A -DIG Prior to Beginning Work
APPROVED BY: Bli
Time Authorized: Void afte days.
Special Conditions: __�i A,
RELEASED BYM Date
jt'�,t r
PERMIT FEE: �3 C), Pn
Restoration Fee:
Receipt No.:
Fund I I I Fee:
Street Cut Dimensions: - x - = $
INSPECTED BY
NO WORK TO BEGIN PRIOR TO PERMIT IS.SUA.NCE
Date
Eng. Div.'March 1989
FIELD INSPECTION NOTES
(Fund I I I - Route copy to Street Dept.)
Diagram:
a
I
CONTRACTOR CALLED FOR INSPECTION 0 YES El NO
Partial Work Inspection by P. W.:
Work Disapproved - By: Date:
FINAL APPROVAL BY: Date:
Eng. Div. July 1985
IrarURNIN
AVAW*"MbWWCMq=V
r2- 2- (- 9 2? 4 �-- [4
WNG to wint
existing
proposed
Addendum to:
City of Edmonds
Permit Application
Engineering Aide: Kerry Walsh
tural Gas
1
( gx,4� eD e AS
61--
ter main depth un own
Key:
-s- satiliary sewer
-w- wa
-8- gas
water valve
hydrant
815 Mam St. (P 0. Box 1869). Sedde, WA 98111 (M) 622-6767
CITY- OF EDMONDS
DEPARTMENT OF BUILDINGS
CERTIFICATE OF OCCUPANCY
UNIFORM BUILDING CODE, Sec. 306
At 22625 HIGHWAY 99 U — 5/1 V'e— Building Permit Number
Occupancy established by this certificate:
B-1
Fire Zone ---
840046
No. Stories One
Type Const. V - N I Basement
(0
Floor Load signs — in place (per Sec. 2308 U.B.C.) — Capacity signs — posted (per Sec- 3301 (i) U.B.C.)
Floor load and room capacity signs, when required, must remain posted at all times.
10
THE store remodel HAS BEEN INSPECTED AND APPROVED AS COMPLYING WITH
PROVISIONS OF THE EDMONDS BUILDING CODE AND WITH UNIFORM BUILDING CODES.
Issued this twenty-seventh day of pril 84
19
CHIEF BUILDING OFFICIAL By JA 0-402-k , n4, PQWe_-L_
This certificate shall be posted In a conspicuous public area and shall not be removed. mutilated or obscured and shall be main-
tained in legible condition at all times. Any change of occupancy requires a new certificate. re
0�
APPLICATION
for
The City of Edmonds SIDE SEWER PERMT EASMNIENT No . ..........................................
NEW CONSTRUCTION REPAIRS
Zf)z-- e)4 2�c C)
ov,rNER .... ..................................................... CO-NTRACTOR ............................ ..................................................................... PERAUT No
0
...... .. Sci ................................... LEGAL DESCRIPTION: LOT No . .............................................. BLOCK No . ............................................
NAMEOF ADDITION .........................................................................................................................................
Jut\(L) 114-7a
D\la- -TiLs-�a-cl (:)vx Eja-wax
Approved:
DATE................................................ By ... ............ ................... ......... .................. --
C-F)-t1j0PtT=-5JZi0Q PUMPS
PUBLIC WORKS 11EPARINO CHEacusr 07—
BUILDING-P5NIT REVIEW
.(address)
Street Right -of -Way Existin����/(DO��_REQD
Z
Access Easements Existing____ILD
N) 19 TEQD� K)-A-
H
p4
Utility Easement Existl __RE
Lot Per Subdivision Plat
Assessor Map
Site Plan Checked for Accuracy.
Z
Underground Wiring Reqd.
H
0
Check Accuracy of Legal Description
Z
Review by_
Date
4��stixi I g Water Main Size
er
Wat Required
rV3-
Se *ce Line red
Hydrant Size'Existing.
1:4
Hydrant Reqd Per Fire Code-
Siz e
De tector Check Ileter Reqd.
Cross Connection Inspect:�M�—
Fire Department: s
Wat ter Charge Reqd.
Review by.
Date
Septic Tank Design Approved
Date
tic Tank Permit Reqd.
Permit No.
Sanit Sewer Availability
Pro,
1jrM,7ing
Side Sewer Aval J-1-ty
Sanitary Sewer Connectl ee Reqd.
Review by_
Date
Open Ditch Exis
�eq d.
Culvert Reqd.
S
r4
Catch Basin qd.
rate
Indi ite Plan
0
Joul g
Shoul drainage maintain collection. on
r
swale open runoff
Manhole reqd.
Indicate on Site Plan
Soil Conditions and Ground Water Field Checked
Review by.
Date
Revised: 1v10-1977
Page 2
St—r-e-et�aving Reqd.
Curb and Gutte d.
Sidewalk Reqd.
Curb Cut for Driveway Reqd.
Right -of -Way Cons ion Nnnit Reqd.,
Bond or Public Iffpravenmts
Street NaTm Sign Reqd.
Other Signing Reqd.
-0
't Site Inspection node on
�"—::e�Permit Site Inspection nude on.
0
BY: S
WATER
STREET,
E NGINEERING
Sp`egial'Requiren-ents listed in memo to Conminity Development Department,
Building Division
BY N f) n Date
o All item filled in an Building PernrLt Application
BY
Drawings Stanped and Notaitions Made
BY Date
Approved by Public Works Department
ArUlmro'y " A-,nls-
Revised:%1v 10-1977
r
USE !-PERMIT
ZONE
CITY* OF EDMONM?,��-','�;' NUMBER
CONSTRUCTION PERMIT APPLICATION' JOB SUITEIAPT A�
ADDRESS
OWNER NAME,.NAME OF BUSINESS
I, EGAL OF CHECKI SUBDIVISION NO. LID NO.
V4
V_ 5gzAj f OIL (OMPANY' *A'Kr W
LU MAILING ADDRESS
k
Z
9 C/07& hOZ MA Al RD, A/. b).
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP. TESCP Approved 1P_
MQER,,,,, ep RW Permit Reii
CITY
IS11"oll, ROQUIR D DICAT QIj
it 44�b
at set Use Pe
ZU red 0:
I j, IIISIP
S,
'A P
E E PRV RE
MIFTER SIZE, QUIRED
LIN,, SIZ NO. OF FIXTLRES7
T-ji
A N
ES YES 0 NO 0
W Z
P
REMARKS
ITELEFHQNEjJUMSER
CITY V,,i J,
4/6 7 7
4 yr AJA 20,; 4*.N& 7 7
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BY
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ZIP TELEPHONE -NUMBER
FIRE DATED REVIEWED,BY ,
MW�
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8 ATA75hICENSE NUMdER ON DATE
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SIGN, AREA SEPA REVIEW ADS NO.
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,%Des ti in of Property
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EXP
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VARIAWIE OR C
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FEET;.,; H T COVERAGE
SIETBACK$
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REAR
FRONT IDE
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Pro rty�%T 0,4 JA iNg �21 "i. HEMARK6
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FOR ADDITIONAL COMMENTS
30
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I�RE&It� M IN y 5 6�
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ENTIAL"
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COMhOERCIAL Ill, A
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PT.
17
ODIC
CHECKED BY TYPE OF CON, RUCTION CODE OCCUPANT
7 �GRADING.,,' 0,J
GROZ 7
RFPAI CY0S.!,!.,
x
5
�WOODST OVE il" ECTOR OCCUPANT,:.
SPECIAL INSP
PEMO, SH . , , -J� _� �. I AREA
.:0, .1. . . S/SPAJ�1' REQUIRED,, m 1511,
El LOAD
01)
YES
OARA RETAiNI�G vi�AlLtJ "iX
REMARKS 4..*,V,1._01#W1x*_.L1 JV_
CARP r
ROCKIERY
WZI - 1 J1 Z .
?RqqR9SS,jNSPECT10NS PER UBC 305
vkTy) EXPLAIN4
v (TyPiE.9fU 9
E,,BUSINES5.OR ACTI
NUMBER UMBER OF. say
77
WELLING
03 STORIES
/VF
0 OF ",r, 'AR
�,4 t
I _�� I UNITS N =RIWAI.
0
t i 6A1
DESCRIBE WORK TO BE DONE (ATTACH PLOT PL�N
Nb,
'EX �1 E--, FIN4AL"iNSPECTION REWIRED
ChA NGEJ-"-� 1) M11
-n :�4
F,
VALUATION
A 6'
PLAN CHECK
YV BUILDIN
F )o?D
�AT,SOURCEl GLA
T %
PLUMBING
MECHANICAL
'Plan Che'ck Nd.
9�q
This Permit covers work to be done on private property ONLY. GRADINGIFILL
Any construction on the public domain (curbs',�Aldevii
driveways, marquegs, etc.) will require separate permission. STATE SURCHARGE
Permit Application: 180 Days
STORM DRAINAGE FEE
Permit Limit: I Year Provided Work Is StartedWithiri.1180 Days
�'Applicant, on behalf of his ENG. INSPECTION FEE
or her spouse, heirs, assigns and'
successors in Interest, agrees to Indemnify, defend, and hold
W �'. Its, officials,
harmless the City � of Edmonds, Washlngton�,
of
2 employees,#nd agenjs from, Spy and all claims fof 0" '
cc qmiiges
whatdve� n ture, arising directly or Indirectly from h4i Issuance EPOSIT
of this permit. Issuance of this permit shall not Oe!depmed to PLAN CHECK D
modify, waive or reduce any requirement of any�'clty.'ordlnance
0
nor limit In'any way the City's ability to enforce'an��ordinance. TOTAL. AMOUNT'DUE
provision."'
I hereby acknowledge.thit I have read this a atloh; that the
A
,and that I am thit owi6er,'6r -tho duly
pplir
Information given is correct, A17ENTION ",,.APPLICATION APPROV L:
0 P' I '61ty and
authorized agent of the owner. I agree t , omply,m, th THIS PERMIT.. 'This app
licatlon is not 6 permit until,,"
'state laws regulating 6onstrOction; and In doing the Work iuthoriz- AUTHORIZES,
; I ad thereby no person will be I employed In 4folatlo . c; signed by the Building Official or his/her
f.the Labor ONLY THE � 13,�'
WORK NOTED.' Deputy; and fees are paid, and receipt
Code of the State of Washington relating to Worknien's Compensa-
111A� - .. I ",;, . acknowledged In space provided.
27. 1 'L, ;,!"" , _� ly,,�, - �, - I .
ion Insurance and RCW 18. INSPECTION
IGNATURE JOWNER 0 ]DA 'DEPARTMENT
�XE, SIGNED
4TE
CITY I:
IF
"I EDMOND
J r. S
W4
W
EE
AELEA D DAfjf
CALL:FCM
ATTENTION INSPECTIO14
IT IS -UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR ORIGINAL — File YELLOW — Inspector
.771iiii20
A - CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED. USC
CHAPTER 3. PI NK Owner GOLD. — Assessor
1024? ? .
CITY OF EDMONDS
USE
ZONE PER T
MIER
NUMB
CONSTRUCTION PERMIT APPLICATION
jog 6x SUITE/APT W
OWNER NAME NA114E OF BUSINESS
IA-'%A,lc- L—W
9q
Mtlev tljl�)Ie
LEGAL DESCRIPTION CHECKI
SUBDIVISION NO. LID
NO
a:
Lu
Z
MAILING ADDRESS
7076,
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP. TESCP
Approved
CITY Zip
WA W 7
TELEPHON, MBER
; " � �C�
'20 ('01; J02- q 9_;�j
EXISTING — REOUIRED DEDICATION RW
street
Inspection
Per - mit Required
Use Permit Req'd
Required
PROPOS110
Sidewsik
Require d 13
N A M E t� R' ky -7 F q A� 5
METER SI
LINE SIZE
NO. OF FIXTU7]
PRV REQUIRED
uJ
ADDRESS 2 00
YES 13 NO 0
y
/
REMARKS
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L)
CITY ZIP
TELEPRON E NUMB ER
!'Br
L L. eva a
4% 77
NAME A-1,1`iij,' I IVI 7- 0,4'Ai
A L E 1,51 F R
ADDREtS
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(V�tj� IIJA
ENGINEERING MEMO DATED REVIEWED BY
0
9
- --y
CITY ZIP
TELEPHONE NUMBER
Z
-It 99 I
FIRE MEMO DATED REVIEWED BY,_
W
Al 0 7 10, 1,bA & / F
TION
STATE LICENSE NUMBER EX DATE
6199DA q-5
SIGN AREA
SEPA RE IEW
ADB NO.
ALLOWED
PROPOSED
COMPLETE
ehe 16 1�*
Legal Description of Property - Include all easementg
- I �4 jNIL
1EXEMPT
A1000"
SHORELINE#
EXP
VARIANCE OR CU
G REVIEW BY
A�ATE
th
uj
0
SETBACKS — FEET
HEIGHT
LOT COVERAGE!
K
FRONT SIDE REA
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to
Pro ert, '301L -7 L) q 2
" P
Ta. A unt
..
Parcel No.
REMARKS
SEE BACK FOR ADDITIONAL COMMENTS
FINEW
E] PLUMBING
ADDITION
RESIDENTIAL
COMMERCIAL
M , ECH'ANICAL
10,/t
i, i"-
F
LA�j REMODEL
APT,BLDG.
GRADING
CHECKED BY
TYPE OF CQNSTRUCTION
ICODE
OC UPANT
GROULI _V
REPAIR CYDS. x _FT)
:0/*
vo
, 1
WOODSTOVE IM POOL
DEMOLISH INSERT HOT TUB/SPA
-
m4g;w
SPECIAL INSPECTOR j.
,
AREA
OCCUPANT
REQUIRED
E3 YE
40AD
GARAGE F7 RETAINING WALL/
CARPORT I I ROCKERY RENEWAL
REMARKS
0
(TYPE OF USE, BUSINESS OR AFTIVITY) EXPLAIN: �.i
PROGRESS INSPECTIONS PER UBC 305
)A)
A11L
NUMBER
OF
N6MBER OF
DWELLING
CRITICAL
AREAS
NUMBER'
rn
STORIES UNITS
DESCRIBE WORK TO BE DONE (ATTACH PLOT PLAN q lucv4l
i"\ P-A A ?A NEL
FINAL INSPECTION
REQUIRED
0 F"P: ij
VALUATION
FEE
PLAN CHECK FEE
77
,v) r),c I-) P,41 Wr 4 _S
BUILDING
HEAT SOURCE.,
GLAZING
%
PLUMBING
Plan Check No. 14
MECHANICAL
GRADINGIFILL
This Permit covers work to be done on private property ONLY.
Any construction an the public domain (curbs, sidewelks,
driveways, marquees, etc.) will require separate permission.
STATESURCHARGE
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
harmless the City, of Edmonds, Washington. Its offlclal;�
*4� - 4 *
employbes, and agents from any and 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
PLAN CHECK DEPOSIT
modify, waive or reduce any requirement of any city ordinance
nor limit in any way the City's ability to enforce any ordinance
TOTAL AMOUNT DUE
provision."
I hereby acknowledge that I have read this application; that the
ATTENTION
APPLICATION. APPROVAL
information given Is correct; and that I am the owner, or thjB duly
authorized agent of the owner. I agree to comply with city and
THIS PERMIT
This application is not a permit until
state laws regulating construction; and In doing the work authoriz.
AUTHORIZES
signed by the Building Official or his/her
ed thereby, no person will be employed In violation of the Labor
ONLY THE
WORK NOTED
Deputy; and fees are paid, and receipt is
Code of the State of Washington relating to Workmen's Compensa-
acknowledged In space provided.
tion Insurance and RCV/ 18.27,
INSPECTION
SIGNATURE (O�� OR AGENT)
DATE SIGNED
DEPARTMENT
CITY OF
i
OF.,FILCIAL'S ljOGNATURE DATE
Abm
EDMONDS
CALL FOR
VELEA ATE
ATTENTION
INSPECTION
q V
tn�W2 //F /
IT IS -UNLAWFUL TO'USE OR OCCUPY A BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR
RIGINAL — File YEI I I OVJ L Inspector
771-020400
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED, USC
CHAPTER 3.
PINK — Owner GOLD — Assessor
102-87