20040821.pdfDATE RECEIVED
FCITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
O)NNER NAME/NAME OF BUSINRS�
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STATE LICENSE NUMBER
EXPIRATION DATE I CHECKED BY
ROPERTY TAX ACCOUNT PARCEL NO.
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NEW
RESIDENTIAL
PLUMBING / MECH
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ADDITION
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REMODEL
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SIGN
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DEMOLISH
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FIRE ALARM
(TYPE OF USE, BUSINESS OR ACT
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NUMBER NUMBER OF CRITICAL
OF DWELLING AREAS
STORIES UNITS NUMBER
DESCRIBE WORK TO BE DONE
(-(4
PLAN �IIECK NO: j
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: ISO DAYS
UJI
PERMIT LIMIM I 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
(n
IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
M EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
x FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF THIS PERMIT SHALL NOT BE
9 DEEMED TO MODIF'� WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
L3 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
PERMIT EXPIRES
USE P ERMIT
ZONE NUMBER
JOB t �U SUITE/APT#
ADDRES
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
Impact on a uirod 13
EXISTING - PROPOSED Sidewalk Required 13
Underground
REQUIRED DEDICATION- IFT - W,,tng,,qi,,d 0
METER SIZE LINE SIZE NO. OF FIXTURES PAV REQUIRED 0
YES 0 NO 13
cc
REMARKS
OWNER/CONTRACrOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ENGINEERING REVIEWED
FIRE REVIEWED BY
VARIANCE OR CU
_X�
SEPA REVIEW
COMPLETE T
EXP 17
LOT COVERAGE
ALLOWED PROPOSED
PARKING
REO'D I PROVIDED
REMARKS
DATE
DATE Ul
SHORELINE OR ADBN INSPE TI N I BOND
RE 'D POSTED
OYES NO S
SIGN AREA HEIGHT
ALLOWED , PROPOSED ALLOWED PROPOSED
A e\ C --+--
REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT)
FRONT SIDE REAR FRONT LJR SIDE REAR
----------
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LOT AREA PrNING RP
DATE
CHECKED�Y I TYPE OF.CCINSTRVCTIPN I COL)E, I OCCUPANT
SPECIAL INSPECTION JAREA j OCCUPANT
REQUIRED E] YES LOAD
REMARKS z
PROGRESS INSPECTIONS PER UBC 108 1 IBC1 09 / IRC1 09 FINAL INSPECTION REQ'D Ej
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
CALL
FOR INSPECTION
Emit
(425)
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f f I MU RELEAS"Y Dna E
ATTEN N tyk I 1;jjj
ITIS UNLAVTFIU9LTFO USEOR OCCUPYABUILDING OR STRUCTURE U NTILA FINAL
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCU- ORIGINAL,FILE YELLOW-14SPECTO
PANCY HAS BEEN GRANTED. UBC109/IBC110/IRC110- PINK�e&NER GOLD -ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
FEE Description FEE
State Surcharge
ir City Surcharge
Base Fee
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'SAeUPENG I ATION INSURANCE AND RCW 18.27.
SIGNATUREJOWN�ER, R AGENT) DATE SIGNED
PlanChk.Deposit
Receipt #
Total Amt. , Due
J'Receipt # _FZfi�
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Otticial or his/her Deputy: and Fees are paid, and
receipt is acknowledged in space provided.
OFFICIALS SIGNATURE DATE
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......,RETURN ADDRESS: 200410190004 3 PGS
10-19-2004 09:03am $21.00
of. Edmonds, City Clerk SNOHOMISH COUNTY. WASHINGTON
15�h Avenue North
Edn16n&*v-WA*%020
. .............. .
NOT-ICEOFLIMTATION AND COVENANT
ADULT FAMILY HOME
Reference #:
Grantor(s): Additional on pg._
Grantee(s): City of E"bnds
Rng EALM Qtr
Legal Description (abbreviatedY"Ser Twn
OR'--.,`1AV Block_Plat
Assessor's Tax Parcel ID#(s): (1 6 t M 1 %�O (2)
___Asses,rwtS; T&vParOl ID# not yet assigned
WHEREAS, the undersigned owners of property Ideated -at lie 5�
in Edmonds,'*Waslii.ogtbn..-.Iigaily described
below or on the attached Exhibit A, have applied f4jr #`bulldifig permit for
compliance and/or to remodel a structure located on the iIte;.'an*d
WHEREAS, the applicant has notified the City of appllcanto� W6.116i:.to, uiilize the
Improvements and/or to convert an existing single family
fondly home; and
WHEREAS, under the Uniform Building Code the number of 6'cc`ft"Pran'ts:.-6'fi a
structure trigger certain requirements relating to the fire suppression find"bidtfingj
requirements; and
WHEREAS, the City has notified the applicant that the permit wW be Issu
conditioned on limitation of residents to 5 or fewer residents and theIr"
caretakers; and
WHEREAS, the City has Issued a perndt based upon such representations;
NOW, THEREFORE, the undersigned property owners (hereinafter
"Owner") In consideration of the Issuance of a building perndt and in order to
confirm the promises upon which such Issuance is based while providing notice to
any future owners or mortgagors of the property does hereby stipulate, covenant
and agree as follows:
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Covenant: Limitation on Residence. The owner hereby stipulates
.---6d,-6grees that occupancy of the structure as an adult family home shall be limited
r fewer adults and their caretakers as allowed by applicable
..-�rq*lqng-of state law. The owner acknowledges that in the event that the applicant
seiiks.Avi$iqn..of--the applicant's state license to operate an adult family home with
a 3f.groter than 5 residents or attempts to rent, lease or
n occi
Wancy 4..
jr.Pxi`0WiesIdence for additional residents above the
P.
In the current occupancy classification, the structure shall
be v�cited-ihd #lUregidehfial use ceased until such time as the property is brought
Into com*pli=6� rovislons of the State Building Code, under the edition of
p
the Unif0f�n,R611din4, Code then In effect. The owner further stipulates that this
covenant t6 ucbd*-8fi . coIncerns the land so long as the present structure and use
continues ari'd sh �Il rdh,Wih the land to all future purchasers and assigns.
2. S : 'jibi��,,Tra'cC4.6cf�bove stipulation and promises shall apply to and
run with the I;nd WI14--r9p.ect*-to.8 residential structure located at
I
III& 2T-6L0"*.,-,FAm�t%.ds9 Washington and legally described as:
PTM o f-- —1
IijL-,Tt+ V—: A4iC7 -4, IN
3. Notification to Future rchasers and Asslgnees Th6..Pdtifk�atlon
and covenant has been recorded In the records of Snohomish Coii�ty-,"WastiIngton
In order to provide notice to any and all future owners of the : ro e%
P p*rty of t.h
limitation at the current level of Improvement to single families and qdult-.IA ly
home residents fewer than In number.
4. Enforcement In addition to any and other remedies civil or crirffln
which the City may have, the property owner hereby agrees and stipulates
grant of covenant shall entitle the City to enforce by Injunction the provisions of tj.h
code and, In so doing, to recover Its reasonable attorney's fees and costs.
AUTHORIZED FOR RECORDING
of Ed n�
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By:
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D this 0C+06,t- 44Adayof 20
S
AC . GEPTED BY: APPLICANTIPROPERTY
K&i pc� A �A� 1604
Applicant
jeann*i]nejj'JGr'i((-�.'-:'- Applicant
Buildini9gricia
Owner
Owner
COVENANT AND
NOTMCATION
ACKNOWLEDGED:
...,Mortgagor
NOTARY FOR OWNER SIGk�TURES.....,"'
State of Washington
)SS
County orl—Lo i==z
I certify that I know or have satisfactori
signed this instmment, on oath stated that h: s e" auihorrzed to execute the
Instrument and acknowledged It as the (title) of
(name of party on behalf on whom.insfrUment 'was executed) to be
the free and voluntary act of such party for the uses-'and'pi"" .'
mes mentions In this
Instrument. Subscribed and sworn to before me this day of .r<DA C. 'N%%
ce th a
h Wii�
.............
Norms
4vNotary ilic In and for theSiate of Wdshingtod. "Liam
My commission expires
I certify that I know or have satisfactory evidence that
signed this instrument, on oath stated that he/she was authorized 19 -exigufe tbi
Instrument and acknowledged it as the qlde)-4 '
(name of party on behalf on whom Instrument was exe . k!utW) to be%
the free and voluntary act of such party for the uses and purposes mentio ns liil�
instrument. Subscribed and sworn to before me this _ day or
Notary Public in and for the State of Washington.
My conunission expires_
AUTHORIZED FOR RECORDING
City of Edum ds
By: —r1K Dot.:
Page '15 of 77
L-.NTEMMUILDINGWORbLg�WF-COVJ)OCV'DM4
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-7-
CITY CLERK
CITY OF EDMONDS
121 5TH AVENUE NO.
EDMONDS, WA 98020
200410190005 2 PGS
10-19-2004 09:03am $20.00
SNOHOMISH COUNTY. WASHINGTON
COVENANT
For Adult Family Home's Second Kitchen
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Whereas, the Grantor(s) A,66IW4 A- M6,010DA4
hereafter referred to as "Grantor(s)", have received a Building
Permit 4 for property which is zoned single family 1, and is
located at �91-4- ]-�A 4-VN n di ),,7sidentia
tax account parcel number eVS-13106VAAS-06 and legally
described as follows: V%pp-WD�1(
,i::: 13eA0,/+ &Loel!� 000 J --06 -rJJA1-
PW-nor,-� OP --rtZ le-15 b&F - (3E&-1 -')W 0-09 '5D '-rP- 1L4T -rif F, AL67
5i," t5 *D -TpL 175 FT -TPI-5 —144 (!ONS-r Al�(-7 &D '5 1 o5 r--r �1 ff f'-s
PL-r VJ UA —1 133 TR W PL-T -5 L-t,3 -�, -0 --) Q I 65�T -Tf�- 15
p t;r �0 Lj-� -;,D -1- g 3 F-r -f pj� X 0- �5 10 Pr -I- I + C) P.
Whereas, the City of Edmonds has received a building permit application for an Adult
Family Home with a second kitchen to be located in an existing single family residence
in a single family residential zone.
Whereas, pursuant to WAC 388-76-190 an adult family home is considered a residential
use of property for zoning purposes, and are permitted in areas zoned for single family
dwellings.
Whereas, the City desires to approve utilization of a second kitchen in the Adult Family
Home as a reasonable accommodation to the facility as care provider to the disabled for
so long as the second kitchen is utilized, and only utilized, in conjunction with the Adult
Family Home use.
Therefore, in consideration of the City of Edmonds, Washington approving the second
6
kitchen as a reasonable accommodation by issuance of a building permit, the Grantors
agree as follows:
RECEIVED
JAN 0 4 2005
EDMONDS CITY CLERK
1(
1. This covenant and all terms hereof shall be binding on Grantor, heirs, assigns
and successors in interest, and shall be deemed to run with the land and bind all
future owners to the real properties described above.
2. This covenant shall be recorded with the Snohomish County Auditor and
Grantors shall pay for all recording fees.
3. Grantors hereby covenant that the kitchen on the lower, basement floor of the
subject residence can be used only in conjunction with the Adult Family Home
and that the said kitchen shall be removed immediately upon termination of the
Adult Family Home State License 9 for the subject facility
or cessation of use of the property as an Adult Family Home, unless, or until,
zoning laws allow otherwise.
4. The provisions of paragraph 3 above shall be specifically enforceable in the
Superior Court of Snohomish County. The prevailing part shall be entitled to its
attorneys' fees in such a proceeding.
5. Grantors acknowledge and agree that approval of the second kitchen for the
Adult Family Home use and the creation of this Covenant are a reasonable
accommodation of Grantors' rights as a care provider to the disabled and of its
clients' foreseeable needs. The Grantors, therefore, on behalf of themselves, their
successors and assigns do hereby waive any and all claims of the Americans With
Disabilities Act or the Washington Law Against Discrimination which they may
have as of the date of the execution of this Covenant and promise to hold
harmless and indemnify the City, its officers, agents and employees from any
cost, claim or liability which may be incurred in defense of such a claim.
By signing and execution of this Covenant, the parties hereto agree that Grantors are in
compliance with existing zoning regulations.
Signed
Subscribed and sworn to before me this aq day of
C 0
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,,O'T A Fik
PUB00
(P
% OF W AS�
� y Pu ic in (!�fir-the Stary of Washington.
ell I WA
ingat Sf
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I Li I 4kL—,qoshjn ton Sfaf� L!==
7 D-PART ENT
5 IAL& EALTH
S ICES
a
Adult Famil Home' icense
y
License Number: 697600
Pursuant to the laws of the State of Washington and the Minimum Licensing Requirements
of the Department of Social and Health Services, a license, is hereby granted to
REGINA MEDIODIA
to conduct and maintain at 6917 176TH ST SW
city of EDMONDS, Zip Code 98026 County of SNOHOMISH I State of Washington
an Adult Family Home for the care and supervision of adults as follows:
24-hour care for no more than 6 adults
This license shall be in force from the 27th of April, 2005 subject to suspension or revocation for due cause.
Conditions on License, if any:
Licensing Authority
NOTE: The department renewal of a license does not preclude the depa ment fro ta n g any action under WAC 388-76-705, based on inspe ction.
5r indiv' it is issued and at the location above described.
This license is not transferable, and is valid only for use by the corporation, paErtn or individual(s) to whom
Issued by Authority of Chapter RCW 70-12
GARY HAAKENS
MAY
CITY OF EDMONDS
11t, 121 5TH AVENUE NORTH EDMONDS, WA 98020 (425) 771-0220 FAX (425) 771-0221
Website: www.dedmondsma.us
DEVELOPMENT SERVICES DEPARTMENT
Planning - Building - Engineering
January 5, 2005
Regina Mediodia
6917 176"' St SW
Edmonds, WA 98026
RE: Adult Family Home Compliance Permit
Dear Ms. Mediodia,
We are'writing to request a copy of the State license for your Adult Family Home and a copy of
your City of Edmonds business license in order to complete the final City requirements for your
pen -nit. Please provide a copy of each directly to me or mail a copy of each to my attention so
we can final your permit.
If you have any questions concerning this request please don't hesitate to contact me at 425-771-
0220.
Sincerely,
Theresa Umbaugh
Permit Coordinator
Incorporated August 11, 1890
Sister Citv - Hekinan. JaDan
DN
OR
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REQUEST FOR INSPECTION- Adult Family Home
APPLICATION NUMBER:
Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed.
SECTION I - PROPERTY INFORMATION
SITE ADDRESS: (-V I I
PROPERTY OWNER NAME:
LICENSEE NAME (IF DIFFERENT):
ASSESSOR'S TAX/PARCEL #: — — — — — — --- — — —
DAYTIME PHONE:
DAYTIME PHONE:
A complete floor plan must include all sleeping rooms, identified by number (#1, #2, #3 etc.) and all components for
exiting, i.e. stairs, ramps, platform lifts and elevators. (Attach additional sheets if necessary)
SECTION 4 — DISCLAIMER/SIGNATURE BLOCK
I certify under penalty of perjury that the information furnished by me is true and correct to the best of my knowledge, and that I am authorized by
the owner of the above premises to request inspection for and operate an Adult Family Home at this location. I further certify that I have made
application to the Department of Social and Health Services and the jurisdiction for the appropriate license(s) to conduct such business at this
location. I further agree to hold harmless the jurisdiction conducting such inspections at my request as to any claim (including costs, expenses, and
attorneys' fees incurred in the investigation of such claim), which may be made by any person, including the undersigned, and filed against the
jurisdiction, but only where such claim arises out of the reliance of the jurisdiction, including its officers and employees, upon the accuracy of the
information supplied to t�e jurisdiction as a part of this application.
NAME/TME: DATE:
PROPERTY OWN C1 APPLICANT El LICENSEE
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SECTION 5 - INSPECTIO14 CHECKLIST
YES
NO
Home licensed (or applying for license) on or after July 1, 2001
SLEEPING ROOMS
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Sleeping Room #1 0 S "St 0 NS2
Bedroom door is openable from the outside when locked
Closet doors are readily openable from the inside
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Smoke alarm is installed In the bedroom
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20"-wide)
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Sleeping room window has a maximum sill height of 44"
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Sleeping Room #2 0 S R-NSI 0 NS2
Bedroom door is openable from the outside when locked
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Closet doors are readily openable from the inside
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Smoke alarm is installed in the bedroom
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Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24"high; 20"wide)
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Sleeping room window has a maximum sill height of 44"
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Sleeping Room #3 0 S 9-NS1 0 NS2
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Bedroom door is openable from the outside when locked
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Closet doors are readily openable from the inside
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Smoke alarm is installed in the bedroom
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Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
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Sleeping room window has a maximum sill height of 44"
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Sleeping Room #4 0 S Er NSI 0 NS2
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Bedroom door is openable from the outside when locked
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Closet doors are readily openable from the inside
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Smoke alarm is installed in the bedroom
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Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
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Sleeping room window has a maximum sill height of 44"
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Sleeping Room #5 0 S 0 NSI 0 NS2
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Closet doors are readily openable from the inside
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Smoke alarm is installed in the bedroom
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Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
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Sleeping room window has a maximum sill height of 44"
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Sleeping Room #6 0 S 0 NSI 0 NS2
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Bedroom door is openable from the outside when locked
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Closet doors are readily openable from the inside
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Smoke alarm is installed in the bedroom
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Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
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Sleeping room window has a maximum sill height of 44"
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GENERAL
Bathroom doors are openable from the outside when locked
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Smoke alarms are installed on all levels of the dwelling
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All smoke alarms are audible in all parts of the dwelling upon activation of a single device
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Access road and water supply approved by Fire Department
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PASSED 0 CORRECTIONS REQUIRED 0 PERMIT REQUIRED
INSPECTOR: rntt( �nO6�, DATE:
I
FIN A 1, PROJECT APP. ROVAL FORM
TO:
DATE:
MEMO TO: PE 1 00 BUILDING DIVISION
FIRE DEPARTMENT DATE —
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FROM.
PLEAS[-: SIGN
ENGINEERING DIVISION DATE
PLEASE SIGN
PLANNING DIVISION DATE
PLEASE SIGN
PROJECT 14A 60) 01) I'A
SITE ADDRESS___1 _q'_7
PERMIT # 2- ADB DATE INSPECTED__1_L3
DESCRIPTION OF WORK TO BE INSPECTED
A field inspection Nvas conducted to determine compliance with - approved plans. Final approval
s from the above signed Department to the release of
denotes that there are no objection
-anting of
PERFOR IvIANCE BONDS and the gi
__,!:�_�GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
0 Copy of CONDITIONS given to owner/contractor by inspector
I .
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
0 Copy of CORRECTION NOTICE given to owner/contractor by inpector
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Signature
Date 13
1:tenip:b1dg:rom1s:ocapr%,1 3/25/04
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RECORD OF INSPECTIONS
INSPECTOR
DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing * ......................
Wall ..........................
Pier/Porch .................
Retaining Wall ...........
Slab Insulation ..........
PLUMBING:
Underground .............
Rough -In ...................
Commercial Final ......
HEATING:
Gas Test ....................
GasPiping .................
Equipment .................
Commercial Final .......
EXTERIOR SHEATHING
NAILING ..........................
FRAMING........................
FIRST FLOOR FRAMING...
INSULATION ...................
Floor Insulation .........
Wall Insulation ...........
Ceiling Insulation .......
SHEETROCK NAILING ...
SPECIAL INSPECTION ...
MISCELLANEOUS ..........
FINAL APPROVAL FOR
vii�7
OCCUPANCY ..................
'rile initials NIT are Milton
rilollipson, a temporary contract
illspcctor for tile CitY.
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