20040387.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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PLAN CHECK NO:
ZIP ITELEPHONE
ZIP I TELEPHONE
EXPIRATION DATE
PARCEL NO.
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RESIDENTIAL
COMMERCIAL
MULTIFAMILY
GRADING CYDS
TANK
RETAINING WALL
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9 R A TIVI EXP
NUMBER OF
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GLAZING %
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NUMBER 1W
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VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180DAYS
W
IL PERMIT LIMIT: I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
tn 'APPLICANI, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
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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 DIREC FLY OR INDIREC TLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED 10 MODIFY WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
01 NOR LIMIT IN ANY WAY THE CITYS ABILITY 10 ENFORCE ANY ORDINANCE PROVISION
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 WITH CITY AND STATE LAWS REGULATING CONSTRUC-
TION AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
IN V61LATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND FICW 18.27.
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Sir, ATURE VOW�E. 'I OR 1,714T))f DATE SIGNED
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FERMIT EXPIRES
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PERMIT
NUMBER
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ADDRESS
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PLAT NAMEISUBDIVISION NO.
LOT NO
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Appll�ld
RW Parrinit Required
0
C3
Street Use Permit Rect'd
13
EXISTING - PROPOSED
InsprictionFlectinfed
sidewalk Required
REQUIHED DEDICATION-
FT
underamind
wiring required
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
0
YES13 NO 0
3
cc
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REMARKS
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OWNER/CONIFIACIOR RESPONSIBLE
FOR EROSION CONTROL/DRAINAGE
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ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE ul
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VARIANCE OR CU SHOREL11 E OR ADB# I INSPECTION BOND
REO'D POSTED
10YES 13NO IS
SEPA REVIEW SIGN AREA HEIGHT
COMPLETE EXEMPT ALLOWED , PROPOSED ALLOWED , PROPOSED
1EXP I
LOT COVERAGE REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (Fr.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
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PARKING LOT AREA I PLA NG REVIEWED BY DATE 5
REO'D I PROVIDED I N"t - jr I IL
REMARKS S4
CHECKED BY
OF CONSTRUCTION I C
GROUP '
SPECIAL INSPECTION JAREA OCCUPANT,
REQUIRED [] YE LOAD 69
REMARKS
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PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION RE01D 5
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VALUATION
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Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapeinsp.
Recording Fee
CALL
FOR INSPECTION
(425)
771-0220
FEE Description FEE
State Surcharge
City Surcharge
Base Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due
> Receipt #
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.
-FICIALS SIGNATURE DATE
Lkl,j' 5-2-0 -0.�/ —
:�FAST5151BY,/ DATE
A17ENTION I EXT 1333 V111111
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
09103 PRESS HARD -YOU ARE MAKING 4 COPIES
ORIGINAL - FILE YELLOW
PINK - OWNER GOLD -
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DEPAWFIAENT Or
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icense N6m* ber:;' 671100
nimum
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tolb6 Jaws of th '. State f W shingto d the Mi''
-Licensing"Requirements
Pursuant
-�,vices; d.lic6n'seis hereby gran'tied to
:.of t1i&-D&1jktmehtj of Socil�i and Health Sdi
CORPORATION
ORATE HOME CARE
d by N TONIA-POSADAS 0
`If Partn
RATE
ershi�/Corpo�ration, represefite A
to conduct and maintain at 434 12TH PLACE N
Ci ofEI)MONDS: -,�Zip Codd�,98020"Count'y of SNOHOMISH: - State of Washington
adults' as follows:
an Hoffic' f6r the-car6 and-. supervis'ibifof
A&ilt.Farnil'
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re- than 6'ad lis
24 ut care'for no mo U
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sti-1004 subject to sus ension oi- rei�dcati'n f ue c,alus'e.
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his license *h 11 be i ',force,ftbra t ie 22nd of Nn&.
6nditions on License, if any:
Licensing Authority
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�'cti`on"utV_er Wk 388-76-705, based on inspection.
:`�:':...NOTE: The departmient renewal of.a license does not preclude the depart ent fr i taking any a
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I taking any
al(s) i
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This license is nof.traMferable, and is valid only for use by the coi�poratiofi, partne or individual(s) to whom it is ismied and at the location above described.
Issued by Authority of Chapter RCW 70.12
OFc 17 20
RETURN ADDRESS: PERM11 rl"�ER
City of Edmonds, City Clerk
121 5th Avenue North
Edmonds, WA 98020
200409161010 3 PGS
AnA 04:07pm $21-00
09 - I 0� WASHINUVU
SNOHOMISH COUNTY.
NOTICE OF LIMITATION AND COVENANT
ADULT FAXHLY HOM[E
-7_/-70Md.5
Reference #:
Grantor(s): (1 Additional on pg.
Grantee(s): Citv of Edmonds
Legal Description (abbreviated): Sec_i�I_Twn Z-7 Rng Qtr .5e
OR Lot Block —Plat
Assessor's Tax Parcel ID#(s): (1) M5_0 7WO09260 2- (2)
Assessor's Tax Parcel ID# not yet assigned
AUTHORIZED FOR RECORDING
ity of Edmonds
By: Date:
'-Page —/—of
WHEREAS, the undersigned owners of property located at
in Edmonds, Washington, legally described
below or on the attache ' d Exhibit A, have applied for a building permit for
compliance andVor 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 lin-itation of residents to 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:
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1. Covenant: Limitation on Residence. The owner hereby stipulates
and agrees that occupancy of the structure as an adult family home shall be limited
to 6 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 6 residents or attempts to rent, lease or
otherwise provide residence fir additional residents above the
permitted in the current occupancy classification, the structure shall
be vacsited 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 land so long as the present structure and use
continues and shall run with the land to all future purchasers and assigns.
2. Subiect Tract. The above stipulation and promises shall p ly to and
run wJJh the land with espect to a residential structure located at
' X 9
A00.4 Edmonds, Washington and legally described as:
3. ' Notification to Future Purchasers and Assignees., This notification
and covenant has been recorded in the records of Snohomish County, 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 families and adult family
home residents fewer than 7 in number.
4. Enforcement. 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.
AUTHORIZED FOR RECORDING
f Edmonds
Ely- 09ity 0 Date: �?
1 '�--Page,��,- of --2L
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DATED this day of Aoy 2024
ACCEPTED BY: APPLICANT/PROPERTY
OWNER:
1'51-01�1 xv* Applicant
A
Jeannine L. Grat
Building Official
AwIr #
AWAaw Ad" 67114�9
. Owner
COVENANT AND
NOTIFICATION
ACKNOWLEDGED:
Mortgagor
NOTARY FOR OWNER SIGNATURES
State of Washington )
I )ss
County ofsuh �Pw (�6
I certify that I know or have satisfactory evidence that -fll'61ud�
signed this instrument, on oath stated that he/she was authorized.to execute the
istru ent,,nd acknowledged itas the 61jiur
r (title) of d
1 U&Mame of party on behalf on whom instrument was executed) to be
the freeand voluntary act of such party for the uses.and�urposes mentio in this
instrument. Subscribed and swor to before me this day of
-C-QNsTANCE M. CURTIS
At-
BLIC
HINGTON
EXPIRES
00
"'9
PUBLIC
Notary Public in and for the State of W WIWBF WASHINGTON
My commission expires_�L�,9 -)
nnmml SION EXPIRES
APRII-9,2007
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 _
I (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
—119
Notary Public in and for the State of Washington.
My commission expire-.
AUTHORIZED FOR RECORDING
—4'ity of Edmon
B y: Date
Page '-1 of—,3' I
L:\TEMMUILDING\FORM,S\ADF_COV.DOC2/10/04
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FINAL PROJEC PROVALFORM
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TO:
JUN 0 7, 2004
DEVELOPhic-,qr SERVICES CTR, DATE:
CITY OF EDMONDS
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE_C_,_1_-__?_—_(L(_
PLEASESIGN
ENGINEERING DIVISION DATE z
PLEASE SIGN 0
PLANNING DIVISION DATE
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PLWF SIGN
PROJECT U5
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PERMIT # C2.3_L2__ADB#__________PATE INSPECTED --I ?.
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DESCRIPTION OF WORK TO BE INSPECTED Xq7 r— 66 A, P 6-1 kdo�- ct> -2
A field inspection was conducted to determine 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 -
0 Copy of CONDITIONS given to owner/contractor by inspector
1 .
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
0 Copy of CORRECTION NOTICE given to owner/contractor by inpector
2.
93
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1:temp:b1dg:fbrms:ocaprv1 3/25/04
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
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Footing ......................
Wall..........................
Pier/Porch .................
Retaining Wall ...........
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Slab Insulation ..........
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P LUMBING:
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Underground .............
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Rough -in ...................
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Commercial Final ......
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HEATING:
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Gas Test .................... --------
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Gas Piping .................
Equipment
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Commercial Final i ......
EXTERIOR SHEATHING
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NAILING ..........................
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FRAMING ........................
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FIRST I FLOOR FRAMING ...
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INSULATION ...................
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Floor Insulation .........
Wall Insulation ...........
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Ceiling Insulation .......
SHEETROCK NAILING ...
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SPECIAL INSPECTION
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MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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