20030599.pdfLVER
DATE RECEIVED U
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMENAME OF BUSINESS
MAILING ADDRESS
CITY Zip ELEPHONE
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NAII�r
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ADDRESS
4-0 10
CITY ZIP ITELEPHONE
Yaftow PolivT
NAME 0 Ify)
CITY ZIP
STATE LICENSE NUMBER
PROPERTY TAX ACCOUNT PARCEL NO.
-0 C)
NEW RESIDENTIAL
13 ADDITION COMMERCIAL
REMODEL MULrlFAMILY
TELEPHONE
13 REPAIR
[:] GRADING CYDS
JXIDEMOLISH
0 TANK
oGARAGE
CARPORT
[3 RETAININGWALL
ROOKERY
(TYPE OF USE, BUSIPJESSOR ACTIVITY11 EXPLAIN:
_�31 nc�`Ii e 4q V", i t -N
NUMBER
NUW8_ER OF
OF
DWELLING
STORIES
UNITS
DESCRIBE WORK TO BE DONE
PERMIT EXPIRES
USE PERMIT
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N U M B E a
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JOB n
SUITE/APT#
ADDRESS kfial -,SL
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PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO,
LID FEE $
TIESCP Approved
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW Permit Required
Street Use Permit R&q'd
EXISTING — PROPOSED
Inspection Roquirild
Sidewalk Required
REQUIRED DEDICATION— FT
UndKground
. . . . . . . . . 13
METER SIZE
LINE SIZE
NO. OF FIXTURES
PFIV REQUIRED
1
1
I
YES[3 NO 13
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
REVIEWED
FIRE REVIEWED BY
DATE
DATE W
M
VARIANCEORCUI
SHOREUNEORADB# I INSPECTION BOND
nON DATE CHECKED BY
REO'D POSTED
i
1,13YEs fe 0 $
SEPA REVIEW
SIGN A REA HEIGHT
COMPLETE EXEMPT
ALLOWED PROPOSED ALLOWED PROPOSED
EXP
,
LOT COVERAGE
REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT)
ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SIDE REAR
COMPLIANCE OR
OF USE
CHANGE
PARKING
LOT AREA PLANNING REVIEWED, BY DATE
SIGN
REO'D PROVIDED
I
3
FENCE
( F'r)
REMARKS
OTHER
FIRE SPRINKLER
FIRE ALARM
Islas
CHECKED BY
OCCUPANT
GROUP
CRITICAL
AREAS
PECIAL INSPECTION
OCCUPANT
NUMBE Ro
REQUIRED [] YE
JAREA LOAD
REMARKS
PROGRESS INSPECTIONS PER LIBC IGO/FINAL INSPECTION REG'D
HEAT SOURCE LOT SLOPE %
'#HECK NO: VESTED DATE
THIS PERMIT AUTHORUES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, siniwims, DRIVEWAYS, MARQUEES, E-rc-1, WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 1180DAYS
PERMIT LIMM I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR L60RE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
IN INTEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER MATURE. 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 CITTS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
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
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
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
WORKMEN'S COMPENSATION INSURANCE AND RCW 16.27.
M
VrOWNEFV�R AGE" DATE 81 ED
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fl)tin,ler 1 _17 A�_
Description
FEE
Description
FEE
Plan Check
State Surcharge
Building Permit
'17�
City Surcharge
Plumbing
Mechanical
Grading
Engr. Revi e w
Engr. Inspection
W�7
Fire Review
plan Chk. Deposit
I
Fire Inspection
Receipt #
Landscape Insp.
Total Amt. Due
Recording Fee
Receipt 0
51-9
CALL
FOR INSPECTION
(425)
771-0220
EXT 1333
APPLICATION APPROVAL
This application Is not a permit until signed by the
Building Official or his/her Deputy: and Fees are paid, and
receipt Is, acknowledged In space provided.
ac
G DAT
SIGN E
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OL
RE"LdSkE'67 Dyt
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- INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK -OWNER GOLD -ASSESSOR
04102 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
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Agency Case No.
200300753
Agency Use Onb-
PUGET SOUND CLEAN
AGENCY
110 Union Street, Suite 500
Seattle, WA 98101-2038
www.pscleanair.org
NOTICE OF INTENI
WM4 7T., =17, F-1 R M. IT,
2003
Agew tft
y
B.
Prop!rt
lOwnert -kyleti s1\vP-r anck X�A e.�ev- Phone: 42Z %4 (,P(041
.M2tilng Address: 'S+ree—�
M ic - - I ci��: edmadT Statewok I zip: 9 0%00
C. Asbatos PLEMMYCLUXLY. MIS F4,722 BE Yom Ram MILMLIZIM
Contractor:
Owner/CEO:
Contractor
Mailing Address:
Phone:
Job No.:
City:
State:
Zip:
Fax:
D. She
Address: City: EArhoridr zi,.:
Site
Mmer Local PhoneAL5 964 VAI
E. Asbestos Survey or
I No.of
Date of Asbestos_7/,,/
Was Friable Asbestos Identified? UYesAWo—
Mat'l Rm med
I Structures:
Survey: 1)_1
Was Nonfriable Asbestos Identified? UYes RNo
1411ach a copy of the survey unlessftlable asbestos
AHERA Buildi
%whmi
Certiflcation N: I/M P .14
inspector, ueg I
Exp. Date: Ri6 :Z F,004
Is identified.
An AIMM Sutwv Is reaulred before a(I deminifflon ormects
F. Demolition
-
I
Start
No. of
IM Tra ng Fire (List Fire Dept.)
Information:
-T
Date: RP tv
Structures:
2. L3 Ordered Demolition (attach cop y of Order)
Demolition
'11110MVP nimetar—imoffing&Uressonback.
Will nonfiriable asbestos be left in place during dcmo? U"Yes K No
I
Contractor:
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If yes, list type and city.
G;.' Friable Asbestos
Work Days: M T W Th F Sa Su
Pro
Aect I formation: Start Date:
Completion Date:
Hours:
Will all fiiable asbestos U Yes
Total Qty� to be Removed: Linear Ft.
Square Ft.
materials be removed? No
List D./Ms) of material to be removed: a M a
H. Asbestos/Demolhion Project Categories: C — C4
SR]L�
Noliftflan ftdodl
Project Demolition
1. Single -Family Residence. Ikepy.
Eu Surcha[C
A. 13 Asbestos Removal Project Only
A. Prior Notice
A. $25
B. �Z Demolition Project (with or without asbestos removal project)
B. 10 Days*
B. $50
'�(Asbestas removal can bealn upon notification; demolition must wait 10 days)
Note: If' the singlefamily residence is owned by onefamily who has been or will be using the residence as their
domicile, the abovee boxes
1A or 1B way be checkeii, A singlefamMy resMence does not include rental jawwrope
muhi-fammy units, or an
mixed -use k8ft.
Z.-L] All Other Demolitions With No Asbestos Removal Pipiect
10 Days
$200
Friable Asbestos Projects (other than Single Family Residence):
Asbestos Demo
---
37Cra 10 - 259 linear feet or a 48 - 159 square feet of asbestos
Prior Notice 10 Days
$150 S50
4. U 260 - 999 linear feet or 160 - 4,999 square feet of asbestos
10 Days
$300 $100
—5771,000 - 9,999 linear feet or 5,000 - 49,999 square feet of asbestos
10 Days
$750 $250
6. 0 > 10,000 linear feet or > 50 ssuare feet of asbestos
10 Days
$2000 $1,000
..000
7. U Emergency Asbestos Project or U Emergency Demolition Project
Prior Notice
Twice Project Fee
(SInglo-randly Itesidences am exempt rroin erner&ecy ree; however, property owners must Mvidc a I
written emergency request)
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1. 1 certify t formation contained In thi.4 notification & SUPPlemental data is. to the best of my knowledge. accurate & complete. Agency Use Only
re Reviewed By
Puget Sound Clean Air Agency Form No.: 66-160 (Revised 3103) TS
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3.
PROJECT APPROVAL
RE -INSPECTED OUTSTANDING ISSUES - GRANTFINAL
S,
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