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Critical Areas Checklist
Site Information (soils/topography/hydrology/vegetation)
1. Site Address/Location:
2. Property Tax Account Number: �j 411,7
3. Approximate Site Size (acres or square feet)%�w
4. Is this site currently developed? _Lfyes; no.
If yes; how is site developed?_,4�IL,4,
5. Describe the general site topography- Check all that appiy.
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: Approx. Depth:
7. Site contains areas of seasonal standing water: ;Approx. Depth:
What season(s) of the year?
8. Site is in the floodway 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,shruhs etc) P--.
11. Obvious wetland is present on site:
For City Staff Use Only
I Site is Zoned?
2. SCS mapped soil type(s)?
3. Wedand inventory or C-A. map indicates wetland present on site?
4..:. Critical Areas inventory or C.A. map indicates Critical Area on site?
5. Site within designated earth subsidence landslide hazard area?
6. Site designated on the Environmentally Sensitive Areas Map?
DETERMINATION
:STUDY REQUIRED CONDITIONAL WAIVER
WAIVER
Reviewed by: - /.,.I e", /,,j— —
Plannej��' Date
PCV01/04M
*90 - 194'�o
City of Edmon&
Critical Areas Checklist
Ile Critical Areas Checklist contained on
this form is to be filled out by any perso n
preparing a Development Permit -
Application for the City of 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).
An applicant, or his/her representative,
must fill out the checklist, sign and date it,
vqii
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.
With a signed copy of this form, the
applicant should also submit a vicinity map
or plotplan 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 pertment information (e.g. site
plan, topography map, etc.) or studies in
conjunction with this Checklist to assist
staff in completing their preliminary
assessment or 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 appropnate column below).
Owner Applicant:
Name
Street Address
City, State, ZIP
Phone
4
Signatur
Date
Applicant Representative:
Name
Street Address
City, State, ZIP Phone
Signature
Date
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NANJE/NAME OF BUSINESS
P / / �9pl P-
USE 1 _6 : PERMIT
ZONE
I NUMBER
JOB
ADDRESS 16 �TA
/I Ve
MAILING ADDRESS
Z
q � 0 le' o I --"A
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP.
TESCP Approved 0
CITY ZIP
.
kd J-1;
'ON UM E
TELEPHONE MBER
1
EXISTING — REQUIRED DEDICATION —
RW Permit Required 11
Street Use Permit
"401f I
111S*Zq1_
PROPOSED
Req*d 0
Inspection Required 0
NAME
I Sidewalk Required C1
METER SIZE
40. OF FIXTUREST.
PRV REQUIRED
YES 0 NO 13
ADDRESS
0
REMARKS
W
W
CITY ZIP
TELEPHONE NUMBER
Z
CITY . ZIP I TELEPHONE NUMBER
STATE LICENSE NUMBER EXPIRATION DATE
Of Property - include all easements
Property
Tax Accou"
Parcel No. 55470
-M-0/2-W-0-3
R NEW
R RESIDENTIAL
D PLUMBING
EP'ADDITION
COMMERCIAL
E] MECHANICAL
OREMODEL
APT. BLDG.
El SIGN
REPAIR
DEMOLISH
GRADING
CYDS.
WOODSTOVE
INSERT
FENCE
.E1 I x _F7)
SWIMPOOL
HOT TUB/SPA
1 GARAGE
:1 CARPORT
RETAINING WALL/
E] ROCKERY
RENEWAL
(TYI�POF USE, PUSIV.SS
OR AFTIVITY)iEXPLAIN: j
. *Pyths
1wm1Ar lyslavrt
ENGINEERING MEMO DATED REVIEWED B7
SIGN AREA
SEPA REVIEW
ADS NO.
ALLOWED
PROPOSED
COMPLETE
1EXEMPT
SHORELINE#
EXP
VARIANCE OR CUI
PLANNING REVIEW BY
DATE-
64�
SET . BACKS —FEE T
HEIGHT
LOT COVERAGE
FRONT ?$' SIDE _7!,,�_'
RE)
2-,;'*
-3 A; -
[CHECKED BY TYPE CONSTRUCTION Cl� OCC
H I
SPECIAL INSPECTOR AREA OCCUPANT
I OUIRED 6YES LOAD
BPI
RE(
F I
EMARKS
P
PROGRESS INSPECTIONS PER UBC 305
0 NUMBER
11
3 OF
a STORIEjfAy/10VUWN1TS
'I
U'
UMBER OF
ELLING
ove
CRITICAL
AREAS
I NUMBER
DESCRIBE WORK TO BE DONE (ATTACH PLOT PLA
h,e ei to r ed acQ_
FINAL INSPECTION
REQUIRED
VALUATION
F
PLAN CHECK FEE
BUILDING
20j70
HEAT SOURCE:
GLAZING'
PLUMBING
Plan Check No. %0_ 4 7
MECHANICAL
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewolks,
driveways, marquees, etc.) will require separate permission.
GRADING/FILL
STATE SURCHARGE
14
Permit Application: 180 Days
Permit Limit: 1 Year - Provided Work Is Started Within 180 Days
I
STORM DRAINAGE FEE
"Applicant, on behalf of his or her spouse, heirs assigns and
successors in interest, agrees to indemnify, def�nd 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 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
nor limit in any way the City's ability to enforce any ordinance
provision."
ENG. INSPECTION FEE
PLAN CHECK DEPOSIT
TOTAL AMOUNT DUE
'.
W
I hereby acknowledge that I have read this application; that the
— I UIP4
information given is correct; and that I am the owner, or the duly
ATTENTION
APPLICATION APPROVAL
authorized agent of the owner. I agree to comply with city and
state laws regulating construction; and in doing the work authoriz-
I
THIS PERMIT
AUTHORIZES
This appli'Cation is not a permit until
ed thereby, no person will be employed in violation of the Labor
ONLY THE
signed by the Building Official or his/her
Code of the State of Washington relating to Workmen's Compensa-
WORK NOTED
Deputy; and fees are paid, and receipt is
tion Insurance and RCW 18.27. -
INSPECTION
acknowledged in space provided.
SIG TURE 0 R ENT) DATYEIGNED
DEPARTMENT
�Pz 7W 1
CITY OF
0 NATURE DATE
EDMONDS
0?6 — 49�
ATTENTION
CALL FOR
MLE -A, DATE
INSPECTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR
771
-P2 0
ORIGINAL — File YELLOW — Inspector
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED; UBC
CHAPTER 3-.-.
-4
PINK — Owner GOLD — Assessor
10247
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