20050904.pdfDATE RECEIVED PERMIT EX I PIRES L �1
PERMIT
CITY OF EDMONDS NUMBER
CONSTRUCTION PERMIT APPLICATION JOB SUITE/APT#
ADDRESS z/v
OWNER NAME/NAME OF BUSINESS
m n AFH,1tVC PLAT NAMEISUB DIVISION NO. LOT NO. LID NO
MAILING ADDRESS I LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved
3.�5'2_4 rL S-W RW Permit Required
Street use Permit Raquired
CITY ZIP T ELEPHONE EXISTING PROPOSED Inspection Requilen
Siduwa:k Requirea
(42,C) 77,�--,S72_4-�L7 REQUIRED DEDICATION FT underground
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NAME METER SIZE LINE SIZE 0. OF FIXTURES PRV REQUIRED
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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CITY ZIP
TELEPHONE
NAME
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ENGINEERING REVIEWED BY DATE
ADDRESS
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FIRE REVIEWED 13Y DATE W
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CITY
ZIP
TELEPHONE
STATE
PROPERTY TAX ACCOUNT PARCEL NO.
0067- -00000/00
NEW
RESIDENTIAL
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ADDITION
COMMERCIAL
MIXED USE
REMODEL
MULTIFAMILY
REPAIR
GRADING CYDS
DEMOLISH
TANK
GARAGE
RETAINING WALL
CARPORT
ROCKERY
(TYPE OF USE, BUSINESS OR ACTIVITX) EALAIN
CHECKED BY
PLUMBING / MECH
COMPLIANCE OR,
�SIGN
FENCE
( X FT.)
OTHER
FIRE SPRINKLER
FIRE ALARM
VARIANCE OR CU
SHORELINEORADBI
INSPECTION
I SEPA
REQ'D
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COMPLETED
EXEMPT
OYES GYNOI
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CA# 9k
ZONE
SIGN AREA
HEIGHT
WAIVERM
ALLOWED PROPOSED
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ALLOWED PROPOSED
STUDY 13
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LOT COVERAGE
REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT LIRSIDE REAR
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PARKING
LOTAREA
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GREVIEWEDBY
DAT 1E
REO'D I PROVIDED
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REMARKS
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TYPE CIF CbMRUCTION I CQPV)
NUMBER NUMBER OF % f I _.�
OF DWELLING SPECIAL INSPECTIO
STORIES UNITS IRED 13YES
DESCRIBE WORK TO BE DONE
REMARKS
CONSULTANT
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GEOTECH REPORT
BY:
STRUCTURAL DESIGN
BY:
VALUATION
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Description
Plan Check
HEAT SOURCE
LOT SLOPE%___7_F
VESTED DATE
Building Permit
PLAN CHECK NO:
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
Grading
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BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: SEE ECDC 119.00.005(A)(5)
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection
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'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND . SUCCESSORS
IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS
2 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 MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CITY'S A131LITY TO ENFORCE ANY ORDINANCE PROVISION. -
Fire Review
Fire Inspection
Landscape Insp.
Recording Fee
CALL
FOR INSPECTION
I HEREBY ACKNOWLEDGE THAT I 14AVE 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'155�p INSATION INSURANCE AND RCW 18:27.
(425)
771-0220
SIGN UREVNE ORAGENT)-
C.72.�
DATE SIGNED
C?10710�c,_
OCCUPANT
GROUP
OCCUPANT
LOAD ,
FEE Description
State Surcharge
City Surcharge
Base Fee
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FEE
Plan Chk, Deposit
Receipt #
Total Amt. Due
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Receipt # I ,
APPLICATION APPROVAr f
This application is not a pennit until signed by the
Building Official or his/her Deputy and rues are paid. and
receipt is acknowledged in space provided
FICLAiLS SIGNAtURIh DATE
1EDBY_ DAIL
1=JX L I JJJ I ' ) �,( I
ATTE+MON �'j wh'
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL -FILE - YELLOW -INSPEC6
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110. PINK -OWNER - GOLD - ASSESSOR
110/04 . PRESS HARD - YOU ARE MAKING 4 COPIES
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SEP 2 2005
PERMIT CoUi"'Ell
ly
REQUEST FOR INSPECTION- Adult Fa Home
APPLICATION NUMBER:
�d.
Applicant must complete sections 1, 2, 3. and 4. Application must be complete to be processL
!�ECTION 1 - PROPERTY IN�ORMATIGN
SITE ADDRESS: 14 VA% 1/t/ ASSESSORS TAx/PARCEL #: — — — — — — — — — — —
SECTION 2'- APPLICANT INFORMATIO
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O=A4A R I A TIME PHONE: 42-5 7*7S-521,4 7
PROPERTY OWNER NAME: Mfig/ ?4K'41V01V DAY
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UCENSEE NAME (iF mFFEReM: C1141W Aff 425-- 77S-,572 47
DAYTIME PHONE:
!�kTION.37 FLOdR PLAN
A complete floor plan must include all sleeping rooms, identified by number (#1, #2, #3 etc.) and all components for
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exiting, i.e. stairs, ramps, platform lifts and elevators. (Attach additional sheets if necessary)
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SECTION 4 DISCLAIM ER[SIGNATURE BLOCK
me is hue and correct to the best of m
I certify under penalty'of perjury that the information fumished by y knowledge, and that I am authorized by
the owner of the above premises to requ est inspection for and operate an Adult Family Home at this location. I further certify that I have made
application to the Department of Soda[ and Health Servi ces and the jurisdkdon.fbr 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 an y 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
jurisdicdort, 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 the jurisdiction as a part of this application.
912-'
NA ME/TITLE: MAP, 1A DATE:
Pr PROPERTY OWNER APPLICANT 0 LICENSEE
MeAl stimuli -
YES
NO
Home licensed (or applying for license) on or after July 1, 2001
SLEEPING ROOMS
Sleeping Room #1 0 S n NSI EI'NS2
Bedroom door is openable from the outside when locked
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Closet doors are'readily openable from the inside
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 F.1 NS I ffNS2
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Bedroom door is openable from the outside when locked
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L -loset 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 minimurn net openable area of 5.7 sf. (minimum dimerr-4ons- 24"high; 20"vdde)
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Sleeping room window has a maximum sill height of 44"
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Sleeping Room #3 0 S 0 NSI El"'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 dimensiom- 24" high; 20N wide)
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Sleeping room window has a maximum sill height of 44"
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Sleeping Room #4 0 IS 0 NS1 9'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'v4de)
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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 ErNS2
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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)
Sleeping room window has a maximum sill height of 44"
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Sleeping Room #6 O's 0 NSI 2r 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
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Bathroom doors are openablefrorn 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
PASSED: 0 CORRECTIONS REQUIRED 0 PERMIT REQUIRED
INSPECTOR: no DATE:
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIV IS ION
FROM: ( ------------- FIRE DEPARTMENT DATE
PIXASF SIGN
ENGINEERING DIVISION DATE
PUMP: SIGN
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PLANNING DIVISION DATE
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PLEASE SIGN
PROJECT
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SITE ADDRESS- 0 tq - --------
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PERMIT #906 70!�( ADB# DATE INSPECTED
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DESCRIPTION OF WORK TO BE INSPECTED
A field inspection was conducted to - determine, compliance with approved plans. Final approval
denotes that there are no objections from the above, signed Departm ent 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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El Copy of CONDITIONS given to owner/contractor by inspector
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FAILED FINAL 'INSPECTION - OUTSTANDING ISSUES
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El Copy of CORRECTION NOTICE given.to owner/contractor by inpector
2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT. FINAL PROJECT APPROVAL
Date Signature
1:te111P:�1dg:fornis:ocaprv1 3/25/04