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23618 84TH AVE W
TAX ACCOUNT/PARCEL NUMBER: oo (4 (,e 0 n 1 0 z
BUILDING PERMIT (NEW STRUCTURE):
COVENANTS (RECORDED) FOR:
CRITICAL AREAS: () �� �-2 3 — DETERMINATION: 0 Conditional Waiver E] Study Required �qwaiver
DISCRETIONARY PERMIT #'S:
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:_
PERMITS (
3-6
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED:
SEWER LID FEE $:
SHORT PLAT FILE:
SIDE SEWER AS BUILT DATED:
SIDE SEWER PERMIT(S) #:
GEOTECH REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
WATER METER TAP CARD DATED:
LID
LOT: BLOCK:
LATEMP\DSrs\Fomis\Street File Checklist.doc
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CiAf Edmon.ds'
Development Services Department
Planning Division'
Phone: 425.77.1.0220
Fax: 425,.771'.0221
Date Melved: -7/0 :t)
City ,Receipt#:, 9,1(Z155-
dritical Areas rile #6
Ceitical Area.s'phecklist. Fee: :$45.00
Date Mailed -to k
pplicant.
I, C-Jlv;
The Critical Areas Checklist contained on this, form is to A property owner, or his/her,- authorized representative,
be filled out by any person preparing a Development, musi'fill out the checklist sign and date i
Permit Application for the City of Edmonds prior to' to the'City. The City will . ' . - t, �nd�submit it
retew,the checklist make a
his/her submittal of the application to the City. v1 , 0
precw�ory site visit, and.make - a determination, of the
The purpose of the Checklis ' t is to enable City stgff to subsequent steps necessary to complete a dev�loprnent
. �_; I permit application.
aeterirdne whether any potential Critical Areas M, or
may be, present on the subject property. The information Please submit a vicinity�!miap'',,�albng 'with the..si'
gned copy
needed Jo, complete the . C hecklist:- should, be, easily zqf this form to assist City, - staff in finding and 166a the
available from of the site or data available
gific,piece pf.property, descril on this form In
ritica es- m addition, the applicant shall include other pertinent
(e.g. site '01inj 'topography map, etc.) or
studies *in conjunction witYthis Checklist to assistant staff
in completing their preliminary assessment of the site.
IM
The undersigned applicant andlT&' =eri heirs, Zan-37�'s`igns, in consideration on the processing,of the application agrees
I -
to release, inderrinify, defend and hold the City of Edmonds harmless frorn any and all damages, including reasonable
attorney's fees, arising 66rn any action or infraction' basied.in'who]6 or --part upoin"filse, misl6ading,''iriaccurate or
incomplete information furnished by the applicant, his/her/its agent§, or employees.
By my signature, I cer* that th i f d xhibits-herewi d are true and correct to the best of my
e in orm"
knowledge and that I am authorized to t1huis a licatilo'non the beha f o the wner as listedbelow.
SIGNATURE oF APPLicANT/AGENT DATE
Property Owner's Authorization
By my signature, I 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 staft 6 f the City of Edmonds to enter the subject property for the
purposes of inspection and p7*= 1*
icati I o . n.
SIGNATURE OF OWNER DATE
Owner/Ap pucant:
)2AY �39Z-Z>
Name
7-36,19 47-W /,w e L A
Street Address
City ;j. State zip
Telephone: -712- `SN62-
Email address (opt ional):
AppHcant Representitiv'e: *
4:f1,-1q1Zx yoACAT-44 K45iw
Name
9treet'Addressi
—D 1-16
'C
ity,
zip
Telephone:_
Email Address (optional):
Critical Areas Checklist.doc/3.19-2001
PLANNING DATA
NAME:
.4 DATE: -4/
SITE ADDRESV' Z 3 6 / ff - fft- A�. t�j, PLAN CHK#:-03 - 110
PROJECT DESCRIPTION: S'7-g-
R . EDUCED SITE PLAN PROVIDED?: &esl/ No)
MAP PAGE: CORNER LOT: QLes �/ FLAG LOT: (Yes
I
ZONING: CRITICAL AREAS DETERMINATION M. 00Z 3
LlStudv Reauired:
UJI Waiver
LJ Conditional Waiver
SEPA DETERMINATION:
L1 Fee
U Checklist
L3 APO list w/ notarized form
Ll __�Needed for 500 cubic yards of grading, Shoreline Area- site within 200 ft. of Puget Sound or Lake Ballinger)
UrExempt
SETBACKS:
Required Setbacks:
Street: Z-5, Left Side: RightSide: Rear: /'S7
Actual Setbacks:
Street: 7S Left Side: 7,5" Right Side: 4 Rear: 3
Street map checked for additional setback required? (Yes DNA)
2—DETACHED STRUCTURES: prAo,,- - trves� 4-vbr—, 14. I-dW^
U ROCKERIES: 0-1 5
LJ FENCES/TRELLISES:
L3 BAY WINDOWS / PROJECTING MODULATION: A,,
U STAIRS/ DECKS: ,, C '�,,
PARKING: Required: 2- Actual: 7- ""-6-�r
LOT AREA: 11
LOT COVERAGE' tZkP 1017
Calculations: ---7— 11 01,0
BUILDING HEIGHT:
Datum Point:— �p 4 (—/t'- - f-a" Datum Elevation: /Cb
Maximum Allowed: j 5' -----.Actual Height: (-5Lm=4,r4" -� 17-' f jA" 4 /it.
A.D.U. CREATED?: Yes)
SUBDIVISION:
LEGAL NONCONFORMING LAND USE DETERMINATION ISSUED: Ly—eS—/j1&)
OTHER:
Plan Review
NewBPP1anningDataForm.D0C
RECEIVED
f�RMIT EXPIRES,
CITY OF EDMONDS
USE PERMIT
111E NUMBERse _e9
0
CONSTRUCTION PERMIT APPLICATION
JOB SUITE/APT#
ADDRESS V
. 2W I'm lqve,
OWNER NAMEMAME OF BUSINESS
RA " e / "-5, t,-- 7 Z I^,
PLAT NAME/SUBDIVISION NO.7140.
LID NO.
U
01
LID FEE S
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MAILING ADDRESS
-Z 3 6 /6 61VOW
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING - PROPOSED
REQUIRED DEDICATION- FT
TESCP Approved
RW Peffrdl Required
Street Use Permit Req'd
inspection Required
Sideeralk Required
I Underwounded 13
ZIP
DA10,ep 24
TELEPHONE
20 -7/ 2, �09-7 & z
6
NAME
METER SIZE
LINE SIZE
NO. OF FIXTU
EQUIRED
NO 13
ADDRESS
r7
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ni
C ZIP
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TEL PHONE
Z,5�_-�77/ 53-5-8
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NAME
CBL #
ENGINEERING REVIEWED BY DATE
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ADDRESS
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BY DATE
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CITY ZIP
TELEPHONE
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SHORELINE OR ADBI
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INSPECTION
REO'D
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PBQND
OSTED
$
STATE LICENSE NUMBER EXPIRATION PATE
C4ECKED BY'
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SEPA REVIEW--
�:COMPLE,T,E `,:EXEMPT:,
EXP -
Lot COVE RAGE�_,,,
-ALLOWED �PROPOSED
SIGN AREA ' ' '
'ALLOWED PROPOSED
Rid UIRED,SETPACKS (FT)
":,*R 'SID :REAR
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HEIGHT
�ALLOWED I PROPO ED
S
�PROPOSED SETBACKS (FT.)
FRONT LJRSIDE REAR
!'�Z _3fr
PROPERTY TAX ACCOUNT PARCEL NO.
NEW RESIDENTIAL PLUMBING I MECH
ADDITION COMPLIANCE OR
COMMERCIAL
CHANG, E OF USE
REMODEL MULTIFAMILY SIGN
0 GRADING FENCE
REPAIR CYDS Fl)
PARKING
REO'D PROVIDED 1,,
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.'LOT AREA
.0,16
ING �'01EVIIEWgP BY DATE
PLANN ...
REMARKS
OTHER,�,,-
D EMOLISH TANK
�CAFRPORT
rc
0
GARAGE RETAINING WALL E] F RE SPRINKLER
El ROCKEAY FIRE ALARM_
I[TYPE OF USE, BUSINESS OR AFTIVITY) EXPLAIN;,
CHECKED BY..
TYPE. OFWT CTION..,,
CQPE
.9
OCCUPANT
GROUP
U
NUMBER
OF
STORIES
WUMBEWOF,
DWELLING
UNITS
CRITICAL
AREAS
NUMBER
SPECIAL INSPECTZ;
REQUIRED 0 YES
JARJEA '
fj2
OCCUPANT
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS. INSPECTIONS PERVBC�1108/11FINAL INSPECTION REO'D
z
VALUATION
$ 9
Description FEE Description FEE
Plan Check
State Surcharge
H7URCE GLAZING% 'ACT -SLOPE %
i%wtl/ I �Buildifig P';erm'ii City Surcharge
PLAN CHECK NO: VESTED DATE �Plurrlbing
03 -110
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBILIC
3 DOMAIN (CURBS, SIDEWALKS, DRIVIEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
I= SFPAAATE PERMISSION. Engr. Review
PERMIT APPLICATION: 180 DAYS
PERMIT LIMM I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICAK ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS Fire Review Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS. WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
IALL CLAIMS FOR DAMAGES OF WHATEVER MATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
!3 DEEMED TO MODIFY WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscapelnsp. Total Amt. Due L
0 44�.
NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
Recording Fee Receipt #
I HERE13Y 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 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 Oflicial or his/her Deputy: and Fees are paid, and
IN VIOLATION OF THE LAl1QB CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt Is acknowledged In space provided.
WORKMEN'S.90MVlfR5f9Ri%RANCE AND RCW 18.27.
OFFIC GN7/ DATE
SIGNATI I-Ef (OW;����� DATE SIGNE 1A9 ) I
�xzxj
1425 1 A 4xn -
7A//0 i-P 771-0220
ATTENTION E)ff 1333 IMOEED By D&fE
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL-FILE YEIIOW-ASP,CTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK -OWNER GOLD -ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5,COPIES GREEN - ACCOUNTING