20040598.pdf - LEGACYDATE RECEIVED
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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STATE LICEN E N MBER
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PROPERTY TAX ACCOUNT PARCEL NO.
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PERMIT EXPIRES
LISE PERMIT
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ADDRESS
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PLAT NAME/SUBDIVISION NO. LOT NO.
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EXISTING -- PROPOSED
REQUIRED DEDICATION— FT
METER SIZE I LINE SIZE 1 NO. OF FIXTURES
LID NO.
LID FEE S
TESCP Approved
RW Permit Required
Street Use Permit Req'd
13
inspection Required
13
Sidewalk Required
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Underground
Wiring required
13
PRV REQUIRED
YES 11 NO 13
REMARKS
OWNER/CONTRACIOR RESPONSIBLE FOR EROSION CONiROL/DRAINAGE
CBL h 0 _ pRE.INSpECTION REQUIRED EBRIS
0 STREET To BE CLEANED OF 1)
ENGINEERING REVIEWED BY
SID13 SEWER MUST B13 CAPKI5 AT
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EXPIRATION DATE C �Uy
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NEW
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PLUMBING / MECH
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COMPLIANCE OR
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CYDS
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DEMOLISH
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FIRE SPRINKLER
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DESCRIBE WORK TO BE DONE
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HEAT SOURCE I GLAZING % I LOT SLOPE %
PLAN CHECK NO: VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PunLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT: 1 YEAR - PROVIDED WORK IS STARTED WITHIN 160 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESORS
IN IN1ERESV, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON. irs OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
ALI. CLAIMS FOR DAMAGES OF WHATEVER NATURE. ARISING DIRECTLY Oil INDIRECTLY
FROM 'THE ISSUANCE OF THIS PERMIT. ISSUANCE OF IHIS PERMIT SHALL NOT BE
DEEMED TO MODII`7'� WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
Non LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
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COMPLETE EVIMP(:
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LOT COVERAGE
ALLOWED PROPOSED
PARKING
REO'D I PROVIDED
REMARKS
CHECKED BY
IN��ON REQUIRLNILNIL
REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT.)
FRONT SIDE REAR FRONT UR SIDE REAR
LOT AREA I PLANNING REVIEWED BY
SPECIAL INSPECTION JAREA
REQUIRED [
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INIM
DATE
OCCUPANT
GROUP
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REMARKS REO'D 2-
I PROGRESS INSPECTIONS PER UBC I 08/FINAL INSPECTION 9
VALUATION
Description
Plan Check
Building Permit_
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp-
Recording Fee
I IIERE13Y ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION� THAT THE INFORMATION
, OWL 'ED'
GIVEN is CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER I I AGREE TO COMPLY WITI I CITY AND STATE LAWS REGULATING CONSTRUC-
WIN
TION. AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
IN VIOLATION OFjHE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
W W VE S,
ORKMEN'S RE)�SATION INSURAN E AND RCW IS 27.
S 'I N TU
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SIGNATU NER R AGID (� I
I DATE SIGNED
Y � I
CALL
FOR INSPECTION
(425)
771-0220
FEE Description FEE
State Surcharge
City Surcharge
Base Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due 75
Receipt #
APPLICATION APPROVAL
This application is not a pormil until signed by the
Building Olficial or his/her Deputy: and Fees are paid, and
receipt is ac�nowledged in space provided,
FELCIALS.,SIGNhfURE QATE
FIF
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ATTENTION I r.,& 1
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
0903 PRESS HARD -YOU ARE MAKING 4 COPIES
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ORIGINAL FILE YELLOW - INSPECTOR
PINK - OWNER GOLD - ASSESSOR
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07/21/2004 13:54 M 206 689 4073
PS CLEAN AIR
0001
FAX
Working
Together For Clean Air
TO
FROM
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Name: Ron DenAdel
Name-,
Teri St(ry
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Company: Sound View Home
Company:
Puget S )und Clean Air Agency
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Builders, Inc.
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Fax: (425) 670-3359
Fax:
(206) 6 ;9-4073
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Phonc:
lPhone:
(206) 6 0-4090
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# of Pages:
Date:
July 21 2004
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E] URGENT For review
Please comment
El PI ease reply Please recycle
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Comments:
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A Notice of Intent fonn is not required by Puget S ound Cleaii
Air A rency for the disassembly
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and removal of the steel structure loc ated at 23302 761h Ave W, Edu onds, WA 98026.
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Agency Case No. PUGETSOUND CLEAN AIR Date Received
AGENCY
........ . 110 Union Street, Suite 500
Seattle, WA 98101-2038
W.
www.pselcanair.org
Agency Use Only NOTICE OF INTENT Agency Use Only
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Property Owner: V(2Lx+
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113honc: 'Tv'��D 1-7
Mailin ddress: 70�_
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City: U411ZI/A
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C. Asbestos M"';F PRINT CLEARLY. MIS ff7LLBF)'OIIRRFrUWAfAI[JACIABFI..
Contractor:
Owncr/CEO:
Contractor
Mailing Address:
Phone:
Job No.:
city: State:
Zip:
I Fax:
D. Site IrA _�2 ___1City: Te--'Jwowd� Tzi <go 2c-
Address:
Site
Martager: Dv_� -oca I Ph
E. LJ Asbestos Survey or No. of Date of Asbestos Was Friable Asbestos Identified? LI Yes LJNo
Ll Mat'l Presumed Structures: Survey: Was Nonfriablc Asbestos Iderifified? QYcs L]No
ARERA Building Certification #: Attach a copy of the survey whenfriable asbestos
Inspector: Exp. Date: has not been identified.
An A11111CA Survey is requIrCa vejore au aernourion projects
F. Demolition 1 Start No. or 1. LJ 'rraining Fire (List Fire DepQ
Information: Date: I Structures: 2. L3 Ordered Demolition (attach copy of Order)
Demolition insert demolition contractor's gilingaddrass on PacT--FWill nonffiablc asbestos be left in place during demo? U Yes LJ No
J I e.
Contractor: 'SO V� If yes, list type and qty.
H. Asbestos/Demolition Project Categories:
Notification Period
Project Demolition
1. Single -Family Residence (owner -occupied):
Fee Surcha
A. 0 Asbestos Removal Project Only
A. Prior Notice
A. $25
B. Demolition Project (with or without asbestos removal project)
B. 10 Days*
B. $50
*(Asbestos removal can begin 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 above boxes
]A or 1B may be checked. Ifthis is not an owner -occupied residence, one ofthe categories Usted below must be used. A singlefamily
residence does not include rental property, multi-fignily units, or anv mixed -use bui ' .
2. U All Other Demolitions with no Asbestos removal or Nonfriable Asbestos
10 Days
$200
only
Friable Asbestos Projects (other than Single Family Residence):
Asbestos Demo
_TU �: 10 - 259 linear Rvt and/or �! 48 - 159 square feet of asbestos
Prior Notice 10 Days
$100 $100
4. U 260 - 999 linear feet and/or 160 - 4,999 square feet of asbestos
10 Days
$200 $100
5. U >1,000 linear feet and/or >5,000 s�Mc feet of asbestos
10 Days
$750 $250
__=0. Emergency Asbestos Project or U Emergency Demolition Project
Prior Notice
rwicc Project Fee
(Singic-Family Residences are exempt from emergency fee, however, property owners must provide a
written cmLrgLnnv wl'11�11
I mrtify that the information con)"d in this not ication & supplemental data is, to the best of my knowledge, accurate & complete. Agency Use Only
C)LAVJVI'
Date Reviewed By
Nignature
lkiget Sound Clean Air Agency I-onn No.: 60-160 (Rmised 1/04)TS
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'Me Puget Sound Clean Air Agency requires advance notification before any person comnicnces a friable asbestos project
involving materials equal to or greater in size than 10 linear feet or 48 square feet and for all demolition projects
(regardless of asbestos content) involving structures with a projected roof area greater than 120 square feet (Regulation
III, Article 4). All asbestos removal and demolition notifications must be submitted to the Agency on current Agency
forms. Asbestos removal and demolition proiccts involving materials and structures below the notification threshold are
still subicct to all other requirements of Regulation III, Article 4.
After receiving a complete notification with the appropriate project fee, the Agency will review the form and return a
copy to the asbestos and demolition contractor by mail. ne returned c4py will be your validated notification.
.1. Demolition PLIF" LVTCLEARLE THEWItLPOR
Qmtractor: ffo n
Owner/cl,o:
Mailing Address: C�Cz
7177�
Contractor's
Job /h
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Nty:
State:
Zip: r6
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Fax:
GUIDELINES FOR SUBMITTING AN ASBESTOSIDEMOLITION NOTIFICATION
Step 1. Check the appropriate project type in Box A. Friable asbestos includes popcom ceiling material, sheet vinyl flooring, cement
asbestos board siding, and duct insulation. Nonfriablc asbestos is nornially found in vinyl floor tiles, window putty and most roofing
materials.
Step 2. Enter property owner information in Box B.
Step 3. Enter the asbestos contractor or property owner information, if the property owner is conducting a single-family residential
project, in Box C. 11'rint. clearly this is your return mailing label.
Step 4. Enter the site address for all notifications in Box D. For multi -structure projects, attach supplemental sheet with a site map
(include an address for each site) and a list of the type and amount of friable asbestos to be removed from each structure.
Step 5. Check either asbestos survey or material presurned in Box E. All demolitions require that an Asbestos Ha7ard Emergency
Response Act (AHERA) asbestos survey be conducted by a certified AHERA building Inspector. Attach a copy of the survey to the
notification or a demolition project when only nonfriable asbestos or no asbestos is identif icd on the survey.
Step 6. Enter the project information in Box F. and check the training fire or ordered demolition box ir appropriate (a copy of the
official order must be attached). All asbestos must be removed prior to conducting a training fire. Additional training fire
requirements arc contained in Regulation 1, Section 8.08. If any nonfriabic asbestos materials will be left in place during demolition,
check yes mid list the type and quantity of material.
Step 7. Enter asbestos project information in Box G. List types of friable asbestos material to be removed: surfacing material such as
popcorn ceilings or plaster, sheet vinyl flooring, duct and pipe insulation, cement asbestos board siding or pipe, etc.
Step 8. For owner -occupied Single -Family Residential projects, check BOX HIA for renovation projects or BOX HIB for
demolition projects (with or without asbestos removal). Asbestos removal may be conducted after a complete notification is
received, but demolition activities can only begin on the 10"' day after the notification is received. Note: If the single family
residence is owned by onefamily who has been or nill be using the residence as their domicile, boxes ]A or 113 may be checked. A
singlefamily residence does not include rental property, multi -family uniis, or any mixed -use building.
For Commercial asbestos projects (or projects that do not qualify as Single Family Residential); check the project category 142 -
5 that matches the amount of friable asbestos that will be removed. If a deniolifion is involved, include the appropriate surcharge
(additional fee) in your payment. To file for an emergency asbestos or demolition project, check die appropriate box I — 5 and the
applicable emergency box in 116. All emergency requests must be accompanied by a letter from the property owner demonstrating the
need to conduct the project immediately in accordance with die requirements in Regulation I 11, Section 4.03 (c).
Step 9. Please certify die accuracy and completeness of die inforniation provided by signing die notification in Box I.
Mandatory amendments to the notification arc required for changes that increase the project category, change the types of asbestos
materials to be removed and changes to start date, completion date and work schedule for asbestos projects. No fee is required for
work schedule changes if die contractor is participating in the Agency work schedule fax program. A $25.00 processing fee is
required for all amendments.
Puget Sound Clean Air Agency asbestos regulations and fornis can be downloaded rrom the Agency web page at www.pscleanair.org.
For technical assistance call (206) 689-4058 and for administrative inquiries call (206) 699-4090.
Nget Sound Clean Air Agiuncy Fonn No.: 66-160 (Revised 1/04)TS
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
I -LEASE SIGN
ENGINEERING DIVISION DATEql�qlwoj
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PLEASE SIGN
PLANNING DIVISION DATE
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DATE INSPECTED
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PERMIT ADB#
DESCRIPTION OF WORK TO BE INSPECTED OUVO
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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 Department to the release of
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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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FAILED FINAL INSPECTION - OUTSTANDING ISSUES
[:1 Copy of CORRE CTION NOTICE given to owner/contractor by inpector
1 .
2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
I: ternp:bldg: forms: ocaprv] 3/25/04
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall..........................
Pier/Porch ................. z
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Retaining Wall .... : ...... 0
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Slab Insulation ..........
76-
PLUMBING: -4
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Underground ............. 0 M
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Rough -In ................... __40
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Commercial Final ...... C
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HEATING:
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Equipment ................. n
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Commercial Final ....... M M
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EXTERIOR SHEATHING 0
NAILING .......................... 0 M
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FRAMING ........................ Q 0
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FIRST FLOOR FRAMING ...
INSULATION ................... -i
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Floor Insulation ......... z
Wall Insulation ...........
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Ceiling Insulation ....... z
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SHEETROCK NAILING ...
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SPECIAL INSPECTION ...
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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