20050502.pdfDATE RE CEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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MAILING ADDRESS
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NAME
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PROPERTY TAX ACCOUNT
NEW
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REMODEL
REPAIR
DEMOLISH
EiGARAGE
CARPORT
(TYP��F USE. 13
OF
STORIES
DESCRIBE
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ZIP I TELEPHONE
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PERMIT EXPIRES
PERMIT
NUMBER
JOB
ADDRESS
SUITEIAPT)
PLAT NAMEISUBDIVISION NO.
LOT NO.
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Permit Required
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EXISTING PROPOSED
Street use Permit Required
inspection Required
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Sidewalk Required
13
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REQUIRED DEDICATION
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Underground
Wiring required
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METER SIZE LINE SIZE
NO. OF IFIXTURES
PRV REQUIRED
YES 13 NO13
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REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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NGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE W
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EXPIRATION DATE
CHECKED BY
VARIANCE OR CU
SHORE LINEORADB#
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SIGN AREA
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ALLOWED I PROPOSED
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ALLOWED , PROPOSED
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COMMERCIAL
MIXED USE
MULTIFAMILY
GRADING
CYDS
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PLUMBING I MECH
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( X FT.)
OTHER
LOT COVERAGE
ALLOWED PROPOSED
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REQUIRED SETBACKS (FT.)
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PROPOSED SETBACKS (FT.)
FRONT L/RSIDE REAR
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PARKING
REO'D PROVIDED
LOTAREA
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PLANNING REVIEWED BY DATE
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REMARKS
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RETAINING WALL
ROCKERY
FIRE SPRINKLER
FIRE ALARM
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TYPE OMCTION
CODE
OCCUPANT
GROUP
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NUMBER OF
DWELLING
UNITS
SPECIAL INSPECTION
CONSULTANT
OCCUPANT
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DONE
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VALUAYION
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Description
FEE
Description
FEE
Plan C heck
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State Surcharge
HEATSOURCE
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LOTSLOPE%
VESTED DATE
Building Permit
City Surcharge
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PLAN CHECK NO: eel,
Plumbing
Base Fee
Mechanical
1111111
THIS PERMIT AUTHORIZES ONLY THE WORK WOTED. THIS PERMIT COVERS WORK TO
Grading
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
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PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT. SEE ECDC 19.00.005A)(6)
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
On *APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
in
Fire Review
Plan Chk. Deposit
W AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
_1 IN INTEREST,
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
41�7) Z.) Receipt #
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< 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
0j DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
Landscapelnsp.
Total Amt. Due
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION-6
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Recording Fee
Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT% AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
This application is not a permit until signed by the
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
CALL
Building Official or hisitter Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
receipt is acknowledged in space provided
FOR INSPECTION
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27.
0 1 11 S SIGNATU D TE
SIGN W NER OR AGENT): T SIGN7D
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(4225)
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771-0220
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ATTENTION
EXT. 1333
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IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI-
ORIGINAL -FILE - YELLOW -INSPECTOV
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 I IBC110 / IRC110.
PINK -OWNER - GOLD - ASSESSOR
10/04 PRESS HARD,- YOU ARE MAKING 4
COPIES
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GARY HAAKENSON
X MAYOR
CITY OF EDMONDS
121 5TH AVENUE NORTH EDMONDS, WA 98020 (425) 771-0220 FAX (425) 771-0221
Website: wwwb.edmondsmams
DEVELOPMENT SERVICES DEPARTMENT
Planning Building Engineering.
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June 6, 2005
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Lucila Rad
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174 1076 Avenue West
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Edmonds, Washington 98026
RE: Adult Family Home
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Dear Ms. Rad:
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The purpose of this lett er is. to inforni you -that it has come to the attention of the Building.
licensing
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Division that your adult family horne has not met all local provisions for business
requirements as mandated by WAC 388-76-19091. , The City of Edmonds works closely with
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DSHS to coordinate regulations. State law governing adult family homes is specific in that it is
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the applicants' responsibility to check with the City to ensure all loc I codes are et,.including
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the requirement to obtain a City business license.
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You have already been provided the City handout for Adult Family Homes. please;:.I) submit an
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application for the compliance permit, and, 2) su bmit an executed Adult Family Home Covenant
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-State Adult Family n issued) and
form and, 3) provide a co y of the Home License (if it has bee
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4) submit for a City%business license (fee $65 form enclosed). Once the compliance permit is
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processed your approved copy will be.returned and you can then schedule for the required
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WABO ins w sizes and required smoke detectors.
pection. Please note minimum windo
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If.you have any questions about these requirements please contact me at 425-771-0220 between
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the weekday hours of 9,:00am noo n and 1:00pm to 4:00pm. If not please submit all noted,
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materials to my attention b June 30, 2005.
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Sincerely,
Jeannine L. Graf
Building Official
Incorporated A ugust 11, 1890 1!
Sister City - Hekinan, Japan
CONFORMED COPY
200507110893 3 PGS
RETURN ADDRESS:
07-11-2005 04:29pm $21.00
City of Edmonds, City Clerk SNOHOMISH COUNTY,-WASHINGTON
121 5th Avenue North
Edmonds, WA 98020
NOTICE OF LIMI TATION AND COVENANT
ADULT FAMILY HOME'
Reference #:
Grantor(s): (1) L u r- fe (2) 41 Ead Additional on pgo—
Grantee(s): City of Edmonds
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Legal Description (abbreviated): S c_:—;'Twnff ZAI Rng 4�FaQt
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OR Lot Block
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Assessor's Tax Parcel ED#(s): M o2 7 0 7
Assessor's Tax Parcel ID# not yet assigned
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A THORIZED FOR RECORDING
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By: bate:
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4/40 141 Alle.
WHEREAS, the undersigned owners of property located at Z7
'legally
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below or on.the attached Exhibit A, have applied for building permit for,
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compliance and/or to remodel a structure located on the site; and'
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or
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tion ta utilize the.
WHEREAS, the applicant has notified the City of applicant's inten.
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improvements and/or to convert an existing.single family.structure to an. adult
ffindly home; and
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WHEREAS, under the Uniform Building Code the number of occupants of.a
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structure trigger certain! requirements relating to the fire suppression and exiting
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requirements; and
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WHEREAS� the City has notified the applicant that the permit will be issued
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conditioned on limitation of 'residents to �o or' fewer residents and their
caretakers; and
WHEREAS, the City has Issued a permit based upon such representations;
NOWY THEREFOREp 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 wh e providing notice to,
any future owners or mortgagors of the property does hereby stipulate, covenant
and agree as followse.
1. Covenant: Limitation on Residence. The owner hereby stipulates
and agrees that occupancy of the structure as an adult family home shall be lindted
to (0 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 residents or attempts to rent, lease or
otherwise provide residence for a dditional residents above the
permitted in the current occupancy 'classification, the structure shall
be vacated 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
cture and use,
covenant touches and concerns the land'so long as the present. stru.
continues and shall run with the land to all future purchasers and assigns.
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2. Suhiect Tract. The above stipulation and gr mises.s H apply to and
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runwith the land with respect to a residential structure located at 117gig 76 AlIg
Edmonds, Washington and legally described as:
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-rA( N S19 A/ �s L ot A- E_ /3 A A P gn
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Notification to Future Purchasers and -As'signees. This notification*
and covenant has been recorded. in the records of Snoh omish County, Washington.
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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 65,. in number.
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4. Enforcement. In addition to.any and other remedies civil or criminal
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n this
which the City.may have, the property owner hereby agrees a d stipulates that
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.9s fees and costs.
AUTHORIZED FOR RECORDING
Ci f Edmonds
By: Date::2�/�
Pap 64- of
GARY HAAKENSON
CITY OF EDMONDS
MAYOR
121 5TH AVENUE NORTH EDMONDS, WA 99020 (425) 771-0220 FAX (425) 771-0221
Website: wwwdedrnondsmams
DEVELOPMENT SERVICES DEPARTMENT
8C)" Planning Building - Engineering
September 8, 2005
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Al Rad
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17410 76"' Avenue West
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Edmonds, Washington 98026
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RE: Adult Family Home (q,) i /410 76"' Avenue West, Edmonds
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Dear Mr. Rad:
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Before the City can grant final approval on your Adult Family Home you must submit the
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following documents:
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Copy of the issued State Adult Farnily,Florne License
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If there are extenuating circumstances which would prevent You from fully complying b y
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September 22, 2005 please immediately contact me at 425-771-0220 xtension 1226
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Sincerely
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Jeannine L. Graf
Building Official
1 corporated August 11, 1890
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Sister 0tv Hekinan. JaDan
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RECEIVED
OCT 2 7 2005
wathim rlsmtt
DE FLT ENT 1�1 EDMONDS CITY CLERK
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cense
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License Ntinibe 4
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Pursuant to aw
th ge it'", OWMIs hereby.gMhted to
da llvl�.,A, u.
of th... rtmen Ple"
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slicense'shall.be. in
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Ong!. n, a n, e s F."
jalAes g ion to PTOW.,
a.sp�e
This hom,61as
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c e'if -any: - .4.4,
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Condit' ns on Li
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Licensing AuthoritY
-76-705, based on inspection.
takinj 1'
ar on under WAC 388*
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:NOTE: The depar"ent renewal of a lice se doe W& tht
ffual(s) to whom it Is Issued and at the location above described.
ot transferable, and Is valldonly for se the
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This license.is n.,
Issued by Authority of Chapter RCW 70-12
RECEIVED
in 14 2P
WILDING DE F.
REQUEST FOR INSPECTION- Adult FamilY Home
APPLicATzoN NUMBER:
oc ed
Applicant must complete sections 1, 2, 3, and .4. Application must be complete to be pr ess
#: 0103-79y-:-DA29-�-
SITE DRESS: /C A /A aV, ASSESSORS TAXPARCEL
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DAYTIMEPKONE:�V�
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pRopERTY OWNER NAME:
DAYTIME PHONE:(jL� �0- �7,2� 7
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UCENSEE NAME (IF DRUMM:
WMEMINGrenam
A complete floor plan must include all sleeping rooms, identified by nurn ber (#1, *2, #3 etc.) and all components for
exiting, i.e. stat rs, ramps, platform lifts and elevators. (Attadi additionalsheets if necessary)
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to tile best of my kwwledge, and that I am authiorized by
I certify under penalty of perjury that the infoirmation furnished by me- Is hm and correct cer* dot I have made
ses to request Inspection for and operate an Adutt Family Home at this location. I furdw
the owner of the above premL fbr the appropriate kense(s) t1D conduct such business at this
application to the Department of social and Health Services and the jurisdictim at my request as to any dalm CuKkKiing costs, enmres, and
wmkzs the jtjrMkdm moducting such inspedions
location. I furdw agree to hold h ned, and filed against the
be made by any person, inducring the undef-A
uch which may
atborneys' Fees Incurred In the investigation Of s dam), including its officers and employeesi upon the accuracy of the
but only where such da Im adses out of the relianoe of the Jurisdiction,
Jurisdiction,
information soled to as a part of this appUcatiOn.
DATE: 0
NAME/TrrLE:
*5,OROPERTY. 0WNEV-'NAPPUCAkT 0 UC I ENSEE
17MMM
YES NO
Horne licensed (or applying for license) on or,after July 1, 2001
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Sleeping Room 0 S NSI C1 NS2
Bedloom door is o penable from the outsi de when locked
Closet doors are� readily openable from the inside
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room
Smoke alarm Is installed in the bed jig Me)
window has a minimum net openable area of 5.7 sf. (rNninwm dimerWons- 24't h; 20' w
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Sleeping room
ximum sill height of 44",
Sleeping room window hasa ma 0 S. NSI 0. NS2
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Sleeping Room *2
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Bedr oom door is openable
Closet doors are readily openable from the inside
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Smoke alarm is installed in the bedroom 24" high; 20' wide)
window has a minimum net openab le area of 5.7 sf. (ffinimum dimmoons
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Sleeping mom
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Sleeping room Wi 0 NS2
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Slee ping Room #3
Bedroom door is openable from the outsid e when locked
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Closet doors are readily open able from theinside
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Smoke alarm is installed in the bedroom ble area of 5.7 sf. (ffdnirmm dimensiom- 24, high; 20' wide)
nimum net opena
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Sleeping room
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Sleeping mom wi NSI 0. NS2
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sleeping Room #4
Bed room door is openable from the outside when locked
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Closet doors are readily openable from the inside
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moke alarm is installed in the bedroom 241 high; 20' Wde)
S ble area of 5.7 sf. (rrjWnwm differnimm
has a mitnimum net opena
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window
Sleeping room eight of 44"
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Sleeping Mom window, has a XNS1 0 NS2
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Sleeping Room *S
Bedroom door is openable. from the outside when locked
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Closet doors a re readily openable from the trig de
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Smoke alarm is Installed in the bedroom of 5.7 sf. (n-inimum &nensiom- 24"high; 2(), wide) 6 0
Sleeping MOM window has a minimum net openable area 0
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Sill height of 44"
Sleeping room window has a maAmum 0 NSI 0 NS2
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Sleeping ROOM #6 0
from the outside when locked
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Bedroom door is openable
Closet doors are readily openable from the inside
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-n is installed in the bedroom 0 0
Smoke alan. openable areaof 5.7 sf. (twitimm dimensiom- 240 high; 2V wide)
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Sleeping room window has a minimum net
has a m a)dmurn sill height of 44"
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Sleeping room window
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Bathroom doors are openable from the outside when locked
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Smoke alarms are Installed on all levels of the dwelling ti of a single device
All smoke ala rms are audible in all parts of the dwelling u pon activa on
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Acce§s road and water supply approved by Fire Department
0 PERM rr REQUIRED
0 CORR ECTIONS REQUIRED
PASSED
DATE:
INSPEC`rOR:-
FINAL PROJECT APPROVAL FORM
TO:
DATE: —
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM FIRE DEPARTMENT DATE,�
'E SIGN
ENGINEERING DIVISION DATE
PLEASESIGN
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PLANNING DIVISION DATE
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PLEASE SIGN
PROJECT_'A_ e7H
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SITE ADDRESS
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PERMIT # ADB# DATEINSPECTED
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DESCRIPTION OF WORK TO BE INSPECTED Prr— 4
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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 YINAL PROJECT APPROVAL
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GRANT PROJECT APPROVAL WITH CO NDITIONS NOTED
0 Copy of CONDITIONS given to owner/contractor by inspector
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FAILED,FINAL INSPECTION - OUTSTANDING ISSUES
El Copy of CORRECTION NOTICE given to owner/con.tra.etor by'inpecto r
3.
RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
�SETBACKS .....................
FOUNDATION:
Footing ............ ..........
Wall..........................
Pier/Porch .................
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Retaining Wall ...........
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Slab Insulation ..........
PLUMBING:
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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 .................
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Equipment ................
Commercial Final .......
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EXTERIOR SHEATHING
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NAILING ........... ..............
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FRAMING ........................
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FIRST FLOOR FRAMING...
INSULATION ...................
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Floor Insulation .........
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Wall Insulation ...........
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Ceiling Insulation .......
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SHEETROCK NAILING ...
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SPECIAL INSPECTION ...
1711
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
2.00
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