20040242A.pdfI
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DATE RECEIVFDV
CITY OF EDMONDS
USE PERMIT
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CONSTRUCTION PERMIT APPLICATION
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stvat use Permit Req'd C3
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CITY ZIP TELEPHONE
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inspection Required (3
EXISTING — PROPOSED Sidewalk Required E3
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REQUIRED DEDICArION� FT v�irmg nlqLarrid
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11,1111:� I ER SIZE i 11,11:1:: 111:11�2 NO. OF FIXTURES PRV REQUIRED
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NUMBER
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OF
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PROGRESS INSPECTIONS PER UBC
108/11FINAL INSPECTION
REQ'D a
VALUATION
ADATE
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PLAN CHECK NO:
VESTED
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
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BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURDS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
W PERMIT APPLICATION: IBODAYS
11.
PERMIT LIMIT. 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
U) 'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
�j IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR NDIRECT -Y
x FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF THIS PERMIT SHALL NOT BE
0 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
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0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
MI .......... M..�
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I HEREBY 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 WITI I 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 90M.Rk'NSATION INSURANCE AND RCW 18 27.
_rEAGENT) DATE SYNED
siGNATyF(E !)WNI
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Description
Dian Check
Building Permit
plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
LandscapeInsp.
Recording Fee
FEE Description FEE
State Surcharge
City Surcharge
:�zl —
Base Fee
CALL
FOR INSPECTION
(425)
771-0220
Plan Chk. Deposit
Receipt N
Total Amt. Due
Receipt #
APPLICATION APPROVAL
This application is not a pernit until signed by the
Building Official of his1her Deputy� and Fees ate paid, and
/.') receipt is acknowledged in space provided.
REL
ATTIFtNTION Wk I I jjj
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
L,S SIGlJATyRE DATE
ORIGINAL - FILE YELLOW - INSPECTOR
PINK -OWNER GOLD,ASSESSOR
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r%6ciwy t—ase NO.
PUGET SOUND CLEAN AIR AGENCY
,�!�clvcd
I 10 Union Street, Suite 500
Scattic� WA 98 10 V-20 3'
www.pscicaaair.org 2 5 20'04
200400371 -M A R
NOT,ICE OF RTrENT
A. PrQiect Tvipe: 1. Q Friable
Asbestos igemoval 0V tur.
2, 11 Fdable Asbeitos Removal &-154M911tiot, I _01)erriQl�tion Only
B.
Property Owner:
1Phone: 2
&
Mailing Address:
-A
Ove
City: 6�� "evi 11-
State AJ*_
zip: �/L
C. Asbestos
I r WA1UNGM1(0WJ4_
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Contr2ctor:
Owner/CEO:
6zv
Contractor
.1y1ailing Address:
A el,2
,Phone:
Job No.
City-,
State:
Zip:
�a'x:
D. Site
Address:
7 L -�A
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Cit� am 0 A
Zip: 9�10 z 6
Site
Manager
Local Phone: X_
A'
�"bestos Survey or
No. of
Date of Asbestos
, Yes U[No
Was Friable Asbestos Identified? 19,
13 ra2t'l Presumed
Structures: 2
Survev: 3/0- 6 Y_
'Was Nonfridble Asbestos Identified? Yes (ZNo
Attach a copy of the survey when filable asbestos
%.�RA Building
Certification#: /'00 ��y 0
Inspector: 31,11 �c.A
R o e
Exp. Date: XV /L, ; 5, 0? 0 0,c)
-has not been identified.
n AHERA Survey is requIred before.aU demoUtion proj"%S vj.)� I
Demolition
Istart
'No. o
Training Fire (Ut Fire Dept.)
Inform!ation:
I Date:
Struc es: 2-
2. Ordered Demolition (attach copy of Order)
Demolition [Aseniie=Olx0n'cOn4rac'Or'JmaVingadarejiOnbaa
Will nonfdable asbestQs.be left in place during demo? U Yes 14 No
Coarractor L —
k I A � -�- . — * VA I—L
If yes, list type and qty.,
Friable Asbestos
Project Informatiou:
Start Dat,e:
X)
COMPI tion Date:
Work Days: T & rj�&
Hours: 15. §�
W W all iale asbestos Yes
materials be removed? No
otal Qry. to be Removed: Linew t.
1pr5_0 Sq eFt.
hcrmal System Insulation;
U BoileAFur-a-a-Ce ins. L�D`uct iai. LJ Pipe his.
Od=-.
affacing Mat,l: I U Fireproofing Maints
U Plaster Textured Coatings
Od=-
[isc. Mat'l
I Z3,Ccmcnt_Bd. U C==nt Pipe
14 Friabl2looriQ or R:��'l
Qawr.
AsbestowDemolition Project Categories:
tificalion Period
Project Demolition
.
Single -Family Residence:
-Notice
F ee Surcharze
C3 Asbestos Removal Project Only
A
Prior
B. 10 DaysO
A. $25
O-Dcmolition Project (with or without asbestos removal
dcmmoLition 'L ys)
-(Asbestos removal can begin �En notification;
Ole: If the singlefamily residemie is owned by onefamily whoiiw h-een or will be using the residence as their domicile, the above boxes
I or IB may be checked. A singlefgmily residence does not inel"de rental prope 2'Yf
nitilli-famUy units, or an
i
mL-ced-use bu ing. I
All Other Demolitions With No Asbestos Removzl Proiect
_13—
10 Days
S200
Friable Asbestos Projects (other tha I single Family Residence):
Asbestos Demo
S100
Cl ;> 10 - 259 linear fe-et and/or �_- 48 - 159 square feet of asbestos
Prior Notice 10 Days
S100
S100
C3 2-60 - 999 linear feet and/or 160 - 4,999 square feef of asbestos
10 Days
S200
U > —1.000 Linear feet and/or >5,000 s5 c feet of asbestos
10 Days
S750 S250
U Emergency Asbestos Project or U Emergency Demolition Project
Prior Notice
Twice Project Fee
I
ryemnt rmmemervencv (cc: howeveii-vroperryowncrs must provide a
wlincn emergency request)
I C cra fy Lh�a G!9 forrd contained in this nod ficafion & suppici—L21 d2ta is, to the bcs; t of my knowled9c. &ccuratc & complete. Agency Use Only
Date Reviei-� BY
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11,Qe-d�r `Z'S
I MAP
SHOR I Pi A
6 7e &3;j FOR j,
Ig :_1
ROBER I C. PAYNI-
IN THE NEI OF SECTION 31, 1*21N. R(4[.
tw- Address: 21328 7611) Ave W. STE
0 City of Edmonds
co % Tax 0 5767-000-016-0400 At Lh 7
Zone RM 2.4 EXPIRESIO/V Y,4 're- V ; 2 40T 5
-;X(f /�Y
Set Backs: Front 15.00 feet LEGAL DESCRIPTION:
L-0
M 15.00 feet The South 115.00 feet of Tract 16 Skelton I
X Rear, V-? 11 C%_
Side 10.00 feet Five Acre Tracts, less the South 30.00 feet for street
Volume 6 of Plats on page 21, records of Snohomish Co. WA.
Total Area: 25,759 Sq. Ft. 0
p. o"
bkTUM CrT%4 OF 9DM r0
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purpose of developing a sampling strategy and may not accurately reflect the pmduct'3 designator
for abatement project design purpoGes.
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Type
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1
oewmption
1
Lowbon
1
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ACBM I
Oty
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Mise
L
10
N
Sheet vinyi, brown
Lawdry & kfthen floor
N
NIA
2.00
Surf
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g
Y
popcorn taxtUrg most house GoIllngs
Y
930 of
3.Oa
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joint compouna
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N
N/A
3.Ob
Mlso
L
8
y
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House wall & oalling substrOtOs
N
N/A
Mlsc
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oem vinyl, yellow
Canter bathroom floor
Y
so of
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Y
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gogt (hall) bathroom ftor
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44 of
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N
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West bathroom floor, top layer
N
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lb
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101
N
Sheet vinyl, blue
West bathroom floor. lower layer
N I
N/A
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N
Roof shingle. broym Mob
House Pitched roof am$
N
WA.
a 0 MIS
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3
N
C;omsnt Asbestos Board
Atrium walls & calling* under
Ows & calling tiles
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Misc
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4
1 N
Roof conting, w"te
Corporl roof, top Ayer N
9.0b.d.f
MIK c
1 7
1 N
Roofing tar
carport roof N IWA
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Mlsc
0 6
1 N
Roofing felt
Carport roof N N/A
MISC
0
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Y
Insulation boara
Carport roof, bottom I&YOr N
NIP,
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0
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Roof shingle, grey 3-tab
worK snop roof
N
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11 02
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Misc
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Y
Y
'Joint compound
Sheetroak
WOM SnOP WRIIS & callings N
WOM SnOP Wells & CailinG8 N
NIA
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112.0a
1 Iv 173 c—,
i I
—N Vinyl tllWe, gre
Wor% shop restroom
NIA
Legand
Abom C)Qffrftr AbWe Defintf
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Surf Sirfacing (bvwalk or uprayod 011) FS Fun000nal Speoe
M18C 1146collan0ous HA Homogwous area
0 Aaeumed ACOM FM Friable
2
10 ELIO?MEti� Spo"Es
01� or F-vow"s
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FINAL PROJECT APP ORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUKDfNG DIVISION
FIRE DEPARTMENT DATE ------
TROM:.
ENGINEERING DIVISION DATE 2�
PLANNING DIVISION DATEL --------
PROJE
SITE ADDRESS--
ADB#----.,�_DATE.INSPECTED-4ZZ �01'
PERMIT #
C) IN( A/
D . ESCRIPTION OF WORK TOBE INSPECTED ELL6;6�
A fleld inspection was condu'cted to determine final compliance with.approved plans. Final approval
denotes that there an no ObJectiOus from the above signed Department to the release of
cE BONDS and the granting of.:
PERFORMAN
GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPRovAL w1TH CONDITIONS NOTED
C) Copy of CONDITIONS given to. Owner/cOnftctor by inspector
FARM FINAL INSPECTION OUTSTANDING ISSUES inspector.
cl COP , y of.CORR ECTION NOTICE given to owner/contractor by
2.
3.
RE -INSPECTED OUTSTANDING ISSUES GRANT FINAL PROJECT APPROVAL.
Si
Date----------
ocaprvLdoc.l:temp:bldg:formsIO/OI
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing......................
wall .................
Piet/Porch .................
Retaining Wall ...........
Slap Insulation ..........
PLUMBING:
Un derground .............
Rough -in ...................
Commercial Final ......
HEATING:
Gas Test ....................
Gas Piping .................
Equipment.................
Commercial Final .......
EXTERIOR SHEATHING
NAILING ..........................
FRAMING ........................
FIRST FLOOR FRAMING ...
INSULATION ...................
Floor Insulation .........
Wall Insulation ...........
Ceiling Insulation .......
SHEETROCK NAILING ...
SPECIAL INSPECTION ...
S
MISCELLANEOUS ..........
FINAL APPROVAL FOR VIA
OCCUPANCY ..................
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