20040419.pdf15
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DATE RECEIVED
C1W OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
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CITY ZIP JT;EPHONE
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NAME
CITY
NAME
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ADDRESS
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CITY
ZIP I TELEPHONE
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STATE LICENSE NUMBER
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ZIP TELEPHONE
40- 5 8C) 3 - 303 2-
EXPIRATION DATE CVIECK& 13Y
(2� AL
L NO.
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NEW
El
RESIDENTIAL
PLUMBING / MECH
ADDITION
COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
REMODEL
MULTIFAMILY
SIGN
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REPAIR
GRADING
CYDS
FENCE
( X FT)
[:]
DEMOLISH
TANK
OTHER
EiGARAGE
CARPORT
RETAINING WALL
ROCKERY
FIRE SPRINKLER
FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
NUMBER NUMBER OF CRITICAL
OF DWELLING AREAS
I I I I AJ14
ci STORIES UNITS NUMBER
DESCRIBE WORK TO BE DONE
,b,F co fV A4 155 / 0 300 cl>bw LOA) U-55
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HEAT SOURCE GLAZING % I LOT SLOPE %
PLAN CHECK NO: I VESTED DATE
PERMIT EXPIRES
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USE PERMIT
ZONE NUMBER 9 O(U14
JOB SUITE/APT#
ADDRESS (�C)
`7"
PLAT NAME/SUBDIVISION NO, LOT NO. LID NO.
L LID FEE S
IESCP Approved 0
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Required E3
Street We Permit Req'd 0
EXISTING — PROPOSED Inspection Required 13
Sidewalk Required E3
Underground
REQUIRED DEDICATION— Fr Waing required 13
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES13 NO 13
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REMARKS z
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE a
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FIRE REVIEWED BY DATE tu
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VARIANCE OR CU
SHORELINEORADB#
INSPECTION
I BOND
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OYES ONO
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SEPA REVIEW
SIGN AREA
HEIGHT
1 - EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
EXP
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LOT COVERAGE
REQUIRED SETBACKS (Fr.)
PROPOSED SETBACKS (Fr.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT URSIDE REAR
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PARKING
LOTAREA
PLANNING REVIEWED BY DATE 5
REO'D I PROVIDED
CL
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REMARKS
CHECKED BY I TYPE OF CONST UCTION OCCUPANT
]CODE GROUP
SPECIAL INSPECTION AREA OCCUPANT
LOAD
REQUIRED [3 YES
REMARKS z
PROGRESS INSPECTIONS PER UBC I 08/FINAL INSPECTION REQ'D 5
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VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
FEE Description
State Surcharge
City Surcharge
FEE
Fire Review Plan Chk, Deposit
Fire Inspection Receipt #
Landscapeinsp. Total Amt. Due
Recording Fee Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
CALL Building Official or his/her Deputy: and Fees are paid, and
FOR INSPECTION receipt is acknowledged in space provided/
FIC I SIGNATUR D TE
(4215)
2 / DA*
771-0220 E XEASED BY
ATTENTION tyk I
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 COLD - AS§ESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180DAYS
PERMIT LIMIT. 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE 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 NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFN� WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
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 VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
SIGNATURE (OWNER (,�gE"T�
DATE SIGNED
_7 , ) 11A 2 , 1�'�'90111
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FINAL PROJECT APPROVAL FORM
RECEIVer)
TO:
JUN 0 7 2004
DEVELOPMENT SERVIC DATE:
CITY OF EDMON ES CTR.
DS
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE__4�,
PLWE SIGN
-ENGINEERING DIVISION DATE
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PLWE SIGN
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-PLANNING DIVISION DATE
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PLEASE SIGN
PROJECT
SITE ADDRESS 2� I'l 6 c)
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PERMIT #'-2,00 ADB# DATE INSPECTED 6
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DESCRIPTION OF WORK TO BE INSPECTED 7-1 21!1�n n-1/0AL- SA7,�_Z)
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A field inspection was conducted to determine compliance with -approved plans. Final approval
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denotes that there are no objections from the above signed De artment to the release of
p
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PERFORMANCE BONDS and the granting of:
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GRANT FINAL PROJECT APPROVAL
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GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
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0 Copy of CONDITIONS given to owner/contractor by inspector
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES
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Copy of CORRECTION NOTICE given to owner/contractor by inpector
2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1:temp:b1dg:fbmis:ocaprv1 3/25/04
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AAA TANK SERVICE CO., INC.
729 Kirkland Avenue, Kirkland, NVA 98033
Phone: (425) 803-3032 Fax: (425) 827-1444
CERTIFICATION OF TANK RINSE
The fuel storage tank at the site described below has been pumped and rinsed in general
accordance with applicable Washington State Uniform Fire Code guidelines and local Fire
Department requirements.
Owner/Operator:
Site address: Aldercrest Health & Rehabilitation Center
21400 72nd Avenue West
Edmonds, WA 98020
Snohomish County Parcel No.: 00580700002301
Capacity of tank: 300 szallons
Last substance stored: diesel/fuel oil
Cleaning contractor: XXX AAA Tank Service Co., Inc. (WDOE Service Provider #SO02307)
Other:
Date rinsed: June 4, 2004
Procedure used: --"trip le —rinse it process with radial nozzle
Waste disposal contractor: Basin Oil Co., Inc.
EPA No.: WAD988477501
I.F.C.I. Licensed UST Decommissioning Supervisor on site:
Name: Toby D, Parker License No.: IFCI 1038004-26
Signature: , 49
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall ..........................
Pier/Porch .................
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Retaining Wall ........... 0
Slab Insulation ..........
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PLUMBING:
Underground ............. —1
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Rough -In ................... C=
M 0
0
Commercial Final ...... 0
0 C:
HEATING: M
M Z
GasTest ....................
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Gas Piping . .................
Equipment ................. 0)
0 -n
Commercial Final ....... -n
EXTERIOR SHEATHING M M
NAILING .......................... 0
0
FRAMING ........................ 0 M
C Cn
9W
FIRST FLOOR FRAMING... Q 0
Z
INSULATION ...................
Floor Insulation .........
3:
Wall Insulation ........... z
Ceiling Insulation .......
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SHEETROCK NAILING ... z
0
SPECIAL INSPECTION ...
0
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MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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