20030458.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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MAILING ADDRESS
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CITY ZIP TELEPHONE ic-ect
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NAME
ADDRESS
CITY
ZIP I TELEPHONE
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PERMIT EXPIRES
16SE PERMIT
ZONE gzq NUMBER
JOB
ADDRESS
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APT#
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PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Perrnit Required
Street Use permit RWd
EXISTING — PROPOSED—
inspection Required
SIdewalkRequired
REQUIRED DEDICATION—
FT
underground
Wiring required 13
METER SIZE
LINE SI�E
OF FIXTURES
PRV REQUIRED
YES 13 NO C3
REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLJDRAINAGE
NAME CBL#
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ENGINEERING REVIEWED BY
DATE
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ADDRESS
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CITY ZIP
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7 (P -3
IANCE OR CU SHORELINE OR ADBN INSPECTION BOND
STATE LICENSE NUMBER EXPIRATION DATE CHECKE BY
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REO'D POSTED
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E3YEs 13NO $
SEPA REVIEW %)
GN AR HEIGHT
PROPERTY TAX ACCOU PAR
COMPLETE EXEMPT A ILL
PROPOSED ALLOWED , PPOPOSED
EXP ,
NEW RESIDENTIAL PLUMBING MECH
OR
LOT COVERAGE RIEQUIR7kS
ALLOWED PROPOSED FRONT
KS (Fr.) PROPOSED SETBACKS (FT.)
FRONT LJR SIDE REAR
ADDITION COMMERCIAL COMPLIANCE
CHANGE OF USE
REMODEL MULTIFAMILY SIGN
PARKING LOT AREA
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PLANNING REVIEWfFY DATE
CL
FENCE
REPAIR 0 GRADING CYDS X FT)
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0 DEMOLISH TANK
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GARAGE RETAINING WALL FIRE SPRINKLER
FIRE ALARM_
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CARPORT ROCKERY
(TYPE OF USE, BUSINES,%M ACTIVITY) EXPLAIN:
CHECKED By CODE OCCUPANT
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J=UCTION
GROUP
NUMBER NUMBER OF CRITICAL
OF DWELLING AREAS
I
SPECIAL INSPECTION
OCCUPAN
LOAD
STORIES UNITS NUMBER
JAREA
REQUIRED [3 YES
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS PER LIBC 101111MINAL INSPECTION REG 'D
69 ae"d
VALUATION
Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE WING % LOT SLOPE %
Building P I erm it
City Surcharge
PLAN CHECK NO- - VESTED DATE
Plumbing
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Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
I= BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
:1 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ErC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPILICATION: 160 DAYS
PERMIT LIMM I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMTION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
Fire Review
Plan Chk. Deposit 3 719!=
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
1
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
Landscapelnsp.
Total Amt. Due
0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
Recording Fee
Recelp
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I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATIO NAPPROVAL
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 CONSTRLIC-
CALL
This application Is not a permit until tigned by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
Building
FOR INSPECTION
Official or hlsfhor Deputy: and Fees are paid. and
receipt Is acknowledged In space provided.
MPENSATION INSURANCE AND RCW 18.27.
OFFICIALS SIGNATURE DATE
NE RAGENT) DATE SIGNED
'A'05)
X�RE
C) -5
771-0220
DATE
RE
S Y
ATTENTION
M 1333
.1A
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 YELLOW- INSPEdTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
PINK -OWNER GOLD -ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
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RETURN ADDRESS:
City of Edmonds, City Clerk
121 5th Avenue North
Edmonds, WA 98020
200312010386 3 PGS
12-01-2003 12:37pm $21.00
SNOHOMISH COUNTY. WASHINGTON
NOTICE OF MUTATION AND COVENANT
ADULT FAMILY HOME
Reference #: �200 3
Grantor(s):(1)EL-EWA--0-- 1VhtJ_:2)1 Additional on pg.—
Grantee(s): City of Ed�jQnds
Legal Descrilition (abbreviated): SecA4--TwnefZ&L—itnz z1 t
OR Lot-------JBlock-----Ylat
Assessor's Tax Parcel ED#(s): (2)-
-----Assessor's Tax Parcel ID# not yet assigned
AUTHORIZED FOR RECORDING
i Edmonds
By: Date:
&PagAe of I
WHEREAS, the undersigned owners of property located at-!VTOG 80 41k &%/r- W
9 in Edmonds� Washington legally described
below or on the'attached Exhibit A, have applied for a building permit for
compliance and/or to remodel a structure located on the site; and
WHEREAS, the applicant has notified the City of applicant's intention to utilize the
Improvements and/or to convert an existing single family structure to an adult
family home; and
WHEREAS, under the Uniform Building Code the number of occupants of a
structure trigger certain requirements relating to the fire suppression and exiting
requirements; and
WHEREAS,, the City has notified the applicant that the permit will be Issued
conditioned on limitation of residents to 5, or fewer residents and their
caretakers; and
WHEREAS, the City has issued a permit based upon such representations;
NOW, THEREFORE, the undersigned property owners (hereinafter
"Owner") in consideration of the issuance of a building permit and In order to
confirm the promises upon which such issuance is based while providing notice to
any future owners or mortgagors of the property does hereby stipulate, covenant
and agree as follows:
1. CQXegapt., LoMitafion !QU Reside= The owner hereby stipulates
and agrebs that occupancy of the structure as an adult family home shall be limited
to 5' -or fewer adults and their caretakers as allowed by applicable
provisions of state law. The owner acknowledges that In the event that the applicant
seeks revision of the applicant's state license to operate an adult family home with
an occupancy of greater than 1.1� . residents or attempts to rent� lease or
otherwise provide residence for additional residents above the
5' -_ __ permitted In -the current occupancy classfficatiou, the structure shall
be v4cated and all residential use ceased until such time as the property Is brought
into compliance with the provisions of the State Building Code, under the edition of
the Uniform Building Code then In effect The owner further stipulates that this
covenant touches and concerns the laud so.long as the present structure and use
continues and shall run with the land to all future purchasers and assigns.
M I
2. Subject Tru& The above stipulation and promises shall apply to and
run with the land with respect to a residential structure located at Al*ola Aofu
0 . Edmonds, Washington and legally described as:
Section 30 Township 27 Range 04 Quarter NE - S 100FT OF N 432.28FT OF E 90.2FT OF NEIM SWIM
NEIM SD SEC EXC TH PT-N LY WITBIN FDT - BEG NE COR SD SWIM NJ31/4 TH S AL G. E LX SID
SW1/4.NEI/4332.28FrTPBTHCONTALO�PLN120 -
frM W 16�59FT TH NELY TAP BEING
12FT W OF TPB TH E 12Fr TPB (RD . RM, TO CM , OPED , 'PEP, QCD REC UND AFN 7609080269)
AKA LOT I CITY OF ED SP S-31-76 REC UND AFN 7609080268
3. D10IMeadan to Euture PUrchasen And Assignees. This notification
and covenant has been recorded In the records of Snohomish Countys Washington
in order to provide notice to any and all future owners of the property of the
limitation at the current level of Improvement to single famines and adult family
'home residents fewer than 6 in number.
4. EnfqrcemeUL In addition to any and other remedies civil or criminal
which the City, may have, the property owner hereby agrees and stipulates that this
grant of covenant shall entitle the City to enforce by Injunction the provisions of this
code and, in so doing, to recover Its reasonable attorney's fees and costs.
AMIORIZED FOR RECORDING
By: 42Edmonds
5,40f ate:
Page -.A— of -Z-
a-- -.*i cov
DATED this /0-),- day of U uptc.
ACCEPTED BY:
OWNER:
4-��M
Jeannine L. G)&,,-'
Building Official
/ �A // 14~
NOTIFICATION
APPLICANT/PROPERTY'
Applicant
Applicant
Owner
Owner
COVENANT AND
ACKNOWLEDGED:
Mortgagor
NOTARY FOR OWNER SIGNATURES
State of Washington
- )ss
County 060,bk&4,��
I certify that I know or have satisfactory evidence that 11
signed this instrumen4 on oath stated that belsbe was authorized to execu e the
jnst�uZme "tandd acknowledged it as the 6 U) & go-2 - (title) of2e
name of party on behalf on whom instrument was executed) to be the
and voluntary act of such party for the uses and purpolLes mentions !Mhb
instrument. Subscribed and sworn to before me this dayofA/99L
rC6 N WTA =C E M, M RAS
S
r n nv n Ing in
'I TA
Notary Public in and for the S* te of Wa OTARYPUBLIC
F, shin WATE OF WASHINGTON
My commission expire-q 10*26mn :41MMISSION EXPIRES
I certify that I know or have satisfactory evidence that - - - - - - - -
signed this Instrument, on oath stated that he/she was authorized to execute the
instrument and acknowledged it as the (title) of
(name of party on behalf on whom instrument was executed) to be the
free and voluntary act of such party for the uses and purposes mentions In this
instrument. Subscribed and sworn to before me this day of
19,
Notary Public in and for the State of Washington.
My commission expires
AUTHORIZED FOR RECORDING
By:,4City of Edmonds
9�w ate. -
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WILDING DEPARTMENT
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ADIDRESS
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LAPPROVED DATE..
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BLDG, OFFICIAL
ERMIT NUMBER
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BUILDING DEPT.
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REQUEST FOR INSPECTION- Adult Family Home
A"UCAUON NUMBER.
Aoicant must complete uxtim 1, 2, 3, and 4. Appi jmtIon must becOMplete to be proGessed.
SrrE ADDRESS. D I*n In Ro+it *LK—, W eDMONC6 ASSMR'S TAWARM -------
FWT -391 110fir 1311-11
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PROPEWMER NAME: DAYTM WIONE: SUE a)
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DAWM MM: U —OP
UCENSEE NAME (rDrF8tWFN.
*2, *3 etr-) and all components fbr
A complete fIW plan must indude all sleeping rwns, kwnMW by number V1,
adting, Le. stairs, ramps, platfbrm lifts and elevators. (Attach add itional d%eets If necessafy)
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I or* under penaft y of per)" dot dw InIbmwition ftnMed by m Is bw and Med t1D the beg of my MaWadge, and dut i am wjjwdmd by
an Adult Farnly Hom at this kndw. I hxda on* M I hvve made
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theawnerof the above pren*05 W request kwPOMM fbr Ond operalte
Ser*M and the jurWWW for the appopMte 000ge(s) bD axWuct rich budnew at dft
ov!
Of smw and flob
applicidon bD the DelarbrAt such k"pec"" at RW reqxg as tD any ddm (kKkdM cos% OWN56 Ond
boMm I fimda agme to hold harmles the Mb"an wndW
may be nude by any pown, Including the undw*ned, and fled against the
fm horred In " krmugsWm of vxh Claim), W"
Mhfttlon, Including Its droms and unpiavaek upw ft amvwv Of the
jurisdiction,bAonlywheresuchdbim OkPolotofftrelIMMOfft
Inknation avow to #0 pdsdkUm as a part of tM aPOkMJ()n.
DATE:
MMgMMM
ef PROPMW OMER Uf APPUWAM
CITY CO'Pv
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YES NO
Horne licKOW (or applying for license) on or after July 1, 2001
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SLIM
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Skoong Roocn *1- 0 S R�NSI 0 NS2
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Bedroom door Is OPenalft from the outside when locked
Closet doors are readily OPenable ftm the Inside
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Smoke alarm is installed In the bedroom
41 high V WWO)
ShWing rMn window has a rrjnkmm net openablee area of 5.7 sf. (n**mrn dkmdw& 2 2
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Sleeping roon window has a mwdmum Sill height of 4'r
1 0 NS2
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Shoong Rom *2 0 S vj/NS
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Bedroom door is openable from the outside when locked
Closet doors are M3ft qMW* ftm the Inside
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smoke alarm is installed In the be*wm
240 high,* 2W WO)
Sleeping room window has a minknum nd open" area of S.7 sf. (mmm amobw
winclow has a meodom sill height of 44-
0
ShWong Room *3 0 S Er*NS 1 0 NS2
Er
0
Bedroom door is openable from the outside when lockW
Closet doors are readily openable from to Inside
W
0
smoke aiarm is installed In the bedroom
Sleeping voon windmN has a minimum net openable area of S.7 sf. (mwmum anmww WW; 2vv*le)
20
Er
0
0
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Sleeping,= window has a ma)dmum si 11 height of 44-
Skmong Room #4 0 S MIMI 0 NS2;
M1*0
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Bedroom door �ftwT�ftoutskle when locked
is opena
Closet doors are readily openable from the inside
0
0
Smoke alarm Is Install9d In the bedroom
20
Sleeping room windov� has a minimum net openable area of 5.7 Sf. (ngnkTm amalkms 241 fth WWO)
0
0
0
0
4�F4
i0w, has a nwdmum sill height of 44'
Sleeping room wim
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SMeong Rooin #5 0 S -4"Sl 0 N S2
Bedroom door is openable fTorn the outside when locked
0
0
0
0
Closet dms are readily openable from the Wde
In the bedroom
0
0
Smoke alarm is Irvalled
Sleeping mom window has a minimum net openable area of S.7 sf. (mwmtxn dnwmkw-24v high; 200 WWS)
0
SMOPIng room window has a nwdmum sill height of W
0 S 0 NS2
VNSI
sla"bW Roorn
0
0
Bedroom dw is openable fmm the outskle when locked
Ck)sd doom am madily openable ham the Inside
0
0
13
0
Smoke alarm is inslalled In the bedroom
sleeping room window has a minimum net openable area of 5.7 sf. (mk*mn dnoubw 240 high; 2W WWO)
0
0
Sleeping 1=1 window has a nwimurn sill height of 4'r
0
0
l3athroorn doom are qmdge ftm the outside when locked
0
Snoke alarm am InsWW an all k%qds of the dw&V*
AN sn alarm are audible In all parts of the dweMM Won adWft of a single &-vicze
0
B- 0
0
Amess road and water supply appvied by Fire Deparbrat
/PASSED �Rm REQtMM 0 PERM
REQUUtED
Mt
1/2,A13
FINAL !!ROJECT APPROVAL FORM
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RE -INSPECTED OUTSTANDING ISSUES GRANT FINAL PROJECT APPROVAL
Sign_
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ADULT IF, AMILY HOME LIC'ENOY1
License Number: 648300
Pwsuant to the laws of the State of Washington and the Minimum Licensing Requirements
of the Department of Social and Health Services, a license is hereby grafited to
ELENA CRISTINA IVAN
to conduct and mainWn at 21706 BOTH AVE W
City of EDMONDS, Zip Code 98026 County of SNOHOMISH State of Washington
an Adult Fandly Home for the care and supervision of adults as follows:
24-hour care for no more than 5 adults
This license shall be in force from the 17th'of October, 2003 subject to suspension or revocation for due cause.
This home has a special designation to provide service to pertons with: Dementia
Conditions on License, if any:
1ob Licensing Authority
NOTE: The dr.partinent renewal of a license does not preclude the depa ..nt ng any action under WAC 388-7&705, based on inspection.
--4 This Reense Is not transferable� and Ls valld only for use by the torporation, paVar individual(s) to whom It Is Issued and at the location above described.
9 ity of Chapter RCW 70.12
D Issued by Authon I
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r'DMATE RECEIVED
CITY OF EDMONDS
PERIMIT EXPIRES
PERMIT
NUMBER
CONSTRUCTION PERIVII A PLICATION
JOB
ADDRESS
�12
S APT#
OWNER NAMEINAME OF BUSINESS
�±g
EL,E�J# () - tj
PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
MAILING ADDRESS
LID FEE S
fk
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L/
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Ap=ed
F1w FOrffM
EXISTING - PROPOSED
a treat Use Farrnh Req'd
Inspecdo Requked
SidroralknRequIrod
CITY ZIP
TELEPHONE CC"
I
98o,� 6
REQUIRED DEDICATION-
FT
UndoWWO
w Wo requked
NAME
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES 13 NO C3
APDRESB
REMARKS
OWNER/COkTRACTOR VIESPONdigLE FOR EROSIO ONITROLIDRAINAGE
WI_61 Aw
CITY ZIP
ITELEPHONE
/( 1016it-�y
ZIP I TELEPHONE
STATE LICENSE NUMBER
PROPERTY TAX ACCOUNT -PARCEL
NEW
RESIDENTIAL
ADDITION
0 COMMERCIAL
13. REMODEL
"MULTIFAMItY
REPAIR
GRADING
CYOS
0 DEMOLISH
0 TANK
0 GARAGE
[3 RETAJNINGWALL
CARPORT
ROCKERY
(Tn.PF USE, BUSINESP-PR ACTIVITY)i EXPLAJN:
g /A
&"� �
NUMBER
NUMBER OF
OF
STORIES 1Z
DWELLING
UNITS
DESFfIIBE WORK TO BE DONE
Mi
&]'F ENGINEERING REVIEWED BY
-BY
RE R IQ
C
BY VY IANCE OR CUI S
PLUMBING/MECH
COMPLIANCE OR
CHANGE OF USE
SIGN
[3 FENCE
( _ X_FT)
FIRE SPRINKLER HJ9,#
FIRE ALARM
SEPA REVIEW '
COMPLETE . EXEMPT
LOT COVERAGE I REQUIRE
ALLOWED PROPOSED I FRONT
PARKING I LOT AREA
RE013 PROVIDER,
,� I ..
DATE
( I DATr W
6 -7 ()03
;R ADB# INSPECTION BOND
REO'D POSTED
113YEs 13NO 1$
3N AREA HEIGHT
) - PROPOSED I ALLOWED . PROPOSED
CHECKED BY UCTION
CRITICAL
AREAS SPECIAL INSPECTION AREA
n/
NUMBER JA REQUIRED 0 YES
REMARK
PROGRESS INSPECTIONS PER UBC I
VALUATION
$
Description FEE
Plan Check
PROPOSED SETBACKS (FT)
FRONT LIR SIDE REAR
DATE
ey
OCCUPANT
GROUP e ?'
44 �.o
OCCUPANT
LOAD d5se
INSPECTION REaD
Description FEE
'late Surcharge
HEAT SOURCE
(1^4 Ni
GLAZING %
I
LOT SLOPE %
Building Permit
City Surc e.
PLAN CHECK NO:
VESTED DATE
Plumbing
THIS PERMIT AUTHORrAMS ONLY THE WORK N THIS PERMIT COVERS W�Rk*i6
Mechanicqd,,
111:
85 DONE ON PRIVATE PROPEM ONLM MY CONSTRUCTION ON THE PUBLIC
Grading
2
3
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
t:
SEPARATE PERMISSION.
Engr. Review
PERMITAPPLICATION: 160DAYS
PERMIT UMFr I YEAR - PROVIDED WORK 15 STARTED WITHIN 180 DAYS
Engr. Inspection
SEE BACK OF PINK PMMIT FOR MORE INFORMATION
-APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
Fire, Review
Plan Ch�k. Deposit
3-70-
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS. EMPLOYEES, AND AGENTS FROM ANY AND
Firelrispection
Receipt N
ALL CLAIMS FOR DAMAGES OF WHATEVER MATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
Landscapelnsp.
Total Amt Due
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CrrrS ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
Recording Fee
Receipt #
:I HEFIE13Y ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION
AP ROVAL
GIVEN IS CORRE" 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-
CALL-
This application Is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
Building OtkW or hialber Deputy: and Fees are paid, and
receipt Is acknowledged in space provided.
WORKMERS COMPENSATION INSURANCE AND RCW 18.27.
OFFICIALS SIGNATURE DATE
M E 6WNER`11PR AGENT)
ITU
DATE SIGNED
1111930%
rVAUJI
ell"
06�IA�0 6
771-0220
------- r----- I
RE
AS Y DATE
ATTENTION
EXT 1333
M
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL - FIL N - INSPEACR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
PINK -OWNER - GOLD -ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES
GREEN - ACCOUNTING
NINE
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