20021000.pdfDATE RECEIVED FPERMIT EXPIRES
USE P T
ON RM'
CITY OF EDMONDS � E N �IM . �EO,
CONSTRUCTION PERMIT APPLICATION JOB SUITE�APT-
ADDRESS 21-12 /14 �� ';-
'Fvsfsa6�tr'� / C77 oK PLAT NAMFJSUSDIVSlON NO I LOT NC, L 0,
L�D N
MAILING ADDRESS 0 FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP T%Alll.
_2-la2z, '20q�2 WE LO EXISTING — IPOPOSED.
CITY ZP J�ELEPHONE I
REQUIREDDAICAPOV-1 llHP_[:—Lr4OhLJlEl"E
k:l �Dl_ %tw,
NAME METERSiZE4 baw-or Tj Bl8,OLVAWWQF gmtm,RED
_ I __ _ YES 0 No C)
OWNER/CONTAACTOR RES7ONSMILeTOM
0 WATER METER
PAW
NAME
n-f' I "'Ir A
aoLlw'L, -7h..,,l
EN.INE..'Ng Ctlfil
H Ll�:T ON BACK OF JOB CMW
FIRE REVIEWED BY DATE
CITY ZIF �LEPHOFE
c - &2�5)
Va-161
STATE LICENSE NUMBER eXPIRATION�Ajj
VARIANCE OR CU
SHORELINE OR ADB#
INSP
R
;gig
0 YE!
SEPA REVIEW
COMPLETE EXEMPT
EXP
SIGN AREA
ALLOWED I PROPOSED
HEIGHT
ALLOWED PROPOSED
PROPERTY TAX ACCOUNT PARCEL NO.
NEW RESIDENTIAL LUMBING/MECR
LOT COVERING
ALLOWED PROPEOSED
REQUIRED SETBACKS IFT)
FRONT SIDE REAR
PROPOSED SETBACK$ IF
FRONT UPSIDE FSART)
C] ADDITION C] COMMERCIAL C MPLIANCE OR
CHANGE OF USE
0 REMODEL 0 APARTMENT 0 SIGN
PARKING
REDD
I PROVIDE
DATE
I C3 REPAIR GRADING C,GS n FENCE
11 ( X ;T)
REMARKS
DEMOLISH [3 TAN� C3 OTHER
GARAGE I -I RETAIN] WALL
CARPORT ROCKE NIS RENEWAL
0 BY
L
r. (TYPE OF USE. BUSINESS OR AlIV
CHECKED BY
TYPIF CONSTRUCTION
a
11UPA"
100791
s GROUP
NUMBER I
OF 0)
0 STORIES (7�
NUMBER OF
DWELLING
UNITS I
ITICAL
AREAS
I M.E.
NR :�155
SPECIAL INSPECTOR JAIEA
REQUIRED 0 YES
OCCUPANT
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS PER UBC 1081FINAL INSPECTION REO'
564ot , i �W t
00 1-- - fW4 JI) I A1412rel?-Ak ) Pr�7�, [7)
VALUATION I FEE
PLAN CHECK FES
HEAT SOURCE CLAIMS I
LOT 511PI I,
BUILDING
j qll� -
PLAN CHECK NO:
PLUMBING
MECHANICAL
THIS PERMIT AUTHO 'IZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON,THE PUBLIC
2 DOMAIN (CURBS, SIDEWALKS. DRIVEWAYS, MARQUEES, ETC.) W LL REQUIRE
GRADiNGIFILL
�SURCHAqGE AVY
r/l
SEPARATE PERMISSION.
PE MIT APPLICATION: 180 DAYS
ERG. REVIEW FEES
PERMIT UlAtt I YEAR - PROVID D WORK IS STARTED WITHIN 180 DAYS
SEE SAC K OF PINK PERMIT FOR MORE INFORMATION
END INSPECTION FEE
PPUCANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
LANDSCAPING
INSPECTION FEE
—RECEIPT
IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY 01
2 EDMONDS, WASHINGION, ITSOFFICIALS, EMPLOYEES. AND AGENTS FRO" ANYAND
ALLCI-AIMS POR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLYOR INDIRECTLY
PLAN CHECK DEPOSIT
AT M THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
9 DEEMED CE ANY REQUIREMENT OF ANY CITY OADINANC E
0 M,=FY. WAIVE OR AEDUUTY TO ENFORCE ANY ORDINANC E PROVU310-
NOR L WAY THE CITY'S AS
HECEIPT'�)
I
TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION: THAT rHE INFORMATION
4-PpLicATiON APPROVAL
T UTN.F'�.G G�
ZE SENT 0'
GIVEN ISCORREC ANDTHAT AM THE OWNER. OR THE DULY AUTHORI DA "IT
�
THE OWNEP� I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING .NE'RHl-
CALL
TY,I S, "'P
TION AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BI
IN VOLATION 01 THE LABOR CODE OF THE STATE OF WASHINGTON R
FOR INSPECTI ON
1
Ofk,W .1 F..' D.lut, ..d F .,A Fa,,L
1,1 11 P1111d9ld 11 1plll PI.ldld,
LS �SIGN T RE DATE
WORKMEN'S COMPENSATION INSURANCE AND HOW 18,27.
(425)
DATE SIGNED
e "7
771-0220
EXT 1333
A-'rTENT16N
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGMAL-FILE YELLOW, INSPEC70A
CATE OF OCCUPANCY HAS BEEN GRIA INTED, U.0 SECTION 109 FAX PINK OWNER GOLD -ASSESSOR
Ii:os )<
z
0
d
0
m
IT!
mo
0
80
c
A m
z
o --I
o"n
m M
0 vi
o 'F
I,
c: 0
c CD
M 0
Z
>
z
cn
z
0
m
Asczcy CA;v No.
P t TQET S OtJN-D CLILMN
AGIENCY
I 10 Union Strar, Sialte 500
Swlk, WA 98101-2038
DEC
21D0201-475
�111002
allMMMO =9
NOTICE OF INTENT
A99McYIUJM0Xr-"
L—�Pro I c ct T—vy a � T 1. Asbe stos R * moval 1 2. 0 Asb esto s Remo vil &- D a -moll tion FI-O Dem olitIon, No Xabestos Removal
B. Property
M-
Owucr:- -'7 �--7
PxopertyQwit!(s
I Mailinc Ad IMSS! 9��,PL A jJ7-- ?,19— 1, q,.". blo I 7i- 9AJ71
C. Mti.StOl-
Contractor; eFV&�IW U Z471,Wl
Owner/CM,�?/4/- J?,AIR �)4Fb trp
MailiLgAddress 6 --7,1 t-;, ?I- Aj C
Phone! el"Or
Contractor,,!
Job No.:
T
2
rim:
D.
Ci�: 't�PI)l4w.0,5
&22219�zl
Lsite
:20 14
E. -.--�Gbtituz �urvq or —01 Date Asbestos S*an,ov
pf S.c.-S. � 11 1 L
t,, ieumpd!.- - - - i 12 "1" -/S. C�(
Was FriableAsbestos ldentig Y at RNN.o
Was Nonfrieble Apbasios Idend ad? Yet
Ar4ch a copy of the burygy, iinonfitiable, asbestos is
Idmilied or ifto asbestos Is identified on 3urv!y.
Exp. Dat
F. Demoluldn Training Fire (List Fire I)cp,.,)
hfcrm-adou; I Daiz;*/-/`)---5! 'in';L C� Ordered Demolition (attach copy of Order);
0=11tni:Y '. —I.- .
Will noniritble ubmtw be laft in place ditring d=o? U Yes J4 X
lfy�, listz�_Te and qw.
j:Sjjj,
Ornplcdon Date: 03
Work Days: M Tg?f� F Sa
Hours: 9,.*L)D - q.
Total Ft. soiiar- Ft.
Licit!,
-s
Will all &iab!o asbest,
be removed?
I 0,.her.
7PI2S:,, F1rw=reJC,.iadnaj
e Y 'c
Z52
D- OBY
z
C M
M 0
0
80
C
M M
,4
z
0 -n
n
M M
0
0
C to
M 0
z
.1�
X
z
;I
z
M
literices, a friable asbestos project
nie Puget �ou;id Clean Air Agency requires advance notification before any pareon cons.
involving materials equal to or greater in size than 10 linear feet or 49 Square feet and for all demolition projects (regardless of
Asbestos conteno iny.61ving structures -Aifa a projected roof area greater than 120 square feet (Regulation III, Article 4). Ali
asbestos removal and- demol;fioa notifications must be submitted to the Agency on Current Agency forms. Albistos =oval
ind demolition proiects JnvolYla-male—riils eand stivctures below the notification threshold - s M Subject to all gther
r��ements of Regulation 111, Article 4.
The Ageric . y notifica4t�n form must be used to submit a notification for an asbestos project, a.combitied asbestos and demolition
ri to demolition. After receiving a complete notification with
proj tot and a dimolitibn project where no asbestos is required p or
the appropriate-groject ilce, the Agency will roview the form and ran= a copy to the asbestos and demolition contractor by�,
mail, The returned copy Nvill be your validated notification,
J. D
C=: Owric,/CEO:Z!22��
contractor'i
M�-'I,-ng Addres!L� -,FO hL-t- ul-les Trlb phone: PL,Z2-t-71'L7 Job #: 1
city:327 ZI
2 S t a t 0:::::
GUIDELINES FOR SUBMITTING AN ASSESTOMDEMOLITION NOTIFICATION
$tepl. Check the aprrqpr.*at- proj:c, type in Be% A.
Stop2. Enter property, c�wner information in Box B.
Stop 3. Enter tl-� asbesics contractor or property owner ebrtnatitm� if the property owner is conducting a 5iiaglc-fii�qy residential
projec-., in Box-C, Prim clearly this i� your returninailing label.
Step4. Enter tke siti'Lddress for all notifications in Box D. For multiple-strucraro projects, attach supplemental sheet With a Site =AP
(include an add:aisa foreach sit-) and a list oftlic We and amount offritblo asbestos to be removed from. 4ch strurturc,,
Stop & Clic6k,riLhei asbestos survey or material presumed in Box E. P-11 demolitions require an Asbestos Hazard Bmergoacy
,�oios be conducted by an AHERA certified building Inspector, Attach-a-corrY of surAy results
to dit notiflce6ot� =",bore nonfriable asbestos is identified &n_�L�w �a no ai6estos was identified on the
Step& Enter & projec: infonnation in Box F, and check thetraining fire or ordered domolition if appropriate (a copy ofthe official
order -must be 4r4-.h.d).:if appropriate. Ali asbestos must be removed prior to conducting a training fire, Additional training fire
requircment, ere,coniaLed in Regulation 1, Section 8.08, It any noz.friablo asbestos materials will be left in place during demolition,
che-1; ycs =d lis;:t!:e %pe end quantity ofmaterial.
Step 7. Enter aslb�stos t cot Lvformation it Box G.
'Proj
Stop S. For Single-Fani . Illy Residetitial prcjecas; check BOX HIA for renovation projects, BOX HIB for demolition projects with or
without asbestos rmova.. Asbestos removal may be conducted after a complete notification is received, but demolition activities can
unlybq;1a on the. 10' d,� after the notificatioa is mccived.
For Commercial a6bcsiot projects; check the projoct category H2 - 6 that matches the amount of friable- asbostos; that will be
removed, If a dctnoliti6x. is involved, include the appropriate surcharge (additional fee) in your paymeaL To file for an emergency
asbos:os or derri-olition project, check the appropriate box I - 6 and the applicable emergency box in H7. All emergency recuests must, , -
be bv a lin�r from the nronerty owner dernonstratinst the need to cooduct the ptDivot inamedintelv in accordance with the
roauirv,ntnt� iii Rri-,alatin M. Section 4.03 (0,
Step 9. pleasoee'rz*�y th�.4cccracy and completeness of the information provided by Signing the notification in Box 1,
Mandatory amen&nc= to the notifictition are required for changes that incredso the project category, chose the typos of asbestos
materials to.bo r=ovoii. and work schedule chanSes. No fee is required for work Schedule chan$ts If the contractor is paniolpial!ng in'
the Agrn.y fax rowana. A S2� processing fee is required for all amendments.
Pusolsouadcleitz-A asbestos revalations and forms can download from the Agency web page at www-Psclitanairorg- For
t-cchaloal azs��--c COL,4ct (206) 689-40n Sod for admitistrative hiquirics contact (206) 689-4090,
Z
'4 5i
M
C M
Ma
0
80
a
-49
n =
10
C
0 -n
n
M M
0 Vi
0
0
C
M C)
Z
4
X
Z
9
0
M
FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE —
ENGINEERING DIVISION DATE-1111�Z—QO 73
PLANNING DIVISION DATE —
PROJECT
SITEADDRESS .......... 1'74�
PERmrr#-201:: �022 ADB#------PATEINSPECTED-4l-2J-1-6-03
DESCRIPTION OF,WORK TO BE INSPECTED —
A field inspection was conducted to determine final compliance with approved plans. Final approval
denotes that there are no objections from the above signed Department to the release of
PERFORMANCE BONDS and the granting of:
GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
u Copy ofCONDITIONS given to owner/contractor by inspector
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
u Copy of CORRECTION NOTICE given to owner/contractor by inspector
2.
3,
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date— Sign_-
ocapryl.doc,l:tenv:bldg:fonnsio/oI
z
0
M
M 0
0
80
C
x M
M z
0-4
C2
0
MM
0
0
M
(n
co
0
X
-4
3:
z
--I
2:
co
z
0
A
0
M
. . .. .......
RECORD OF INSPECTIONS
INSPECTOR
DATE APPROVED
SETBACKS .......... ..........
T� J_ t FOUNDATION:
Footing ......................
wall..........................
Pier/Porch .................
z
Retaining Wall ...........
Slab Insulation ..........
PLUMBING:
—j
Underground .............
0 M
C
M
Rough -in ...........
0
0
Commercial Final
C r!
M
HEATING:
ITI
10
a
Gas Test ....................
>
Gas Piping .................
Equipment ...............
Commercial Final
x IT!
ITI
0)
EXTERIOR SHEATHING
0
NAILING ..........................
0
FRAMING ... .....................
M C)
F1 RST FLOOR FRAMING
INSULATION ...................
Floor Insulation
>
z
Wall Insulation ...........
Ceiling Insulation
z
SHEETROCK NAILING
SPECIAL INSPECTION
rn
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................