BLD20170384.pdfExpiration Date: 09/21/2017
Parcel No: 00527900000900
[P11-10113 FRTY OWN FR
ROTH ANTHONY AUGUST BE
21730 95TH AVE W
EDMONDS, WA 98020-3913
Pump contents, triple rinse and fill in p
VALUATION: $0.00
121 5TH AVENUE NORTH EDMONDS, WA 98020
PHONE: (425) 771-0220 - FAX: (425) 771-0221
C/O VON GIGRICH
17552 BALLINGER WY NE
LAKE FOREST PARK, WA 98155
(206)365-0291
undergro
TANKS BY DALLAS
C/O VON GIGRICH
17552 BALLINGER WY NE
LAKE FOREST PARK, WA 98'155
(206)365-0291
LICENSE #: TANKSD*001KF EXP:05/06/2017
I'AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUCTION AND IN DOING THE WORKAUTHORIZED
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,
THIS APPLICATION IS NOT A PERMIT UNTIL SIGNED BY THE BUILDING OFFICIAL OR HIS/HER DEPUTY AND ALL FEES ARE PAID,,
31u/2-017
Signature Print Name Date Released By Date
ATTENTION
ITIS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF
OCCUPANCY HAS BEEN GRANTED. UBC109/ IBCI10/ IRC110
ONLINE APPLICANT ASSESSOR OT1;IER
STATUS: ISSUED_
BLD201703
• Final approval on a projector final occupancy approval must be grantedby the Building Official prior to use or occupancy of
the building or structure. Check the job card for all required City inspections including fin al'project approval and final
occupancy inspections.
• Any request for alternate design, modification, variance or other administrative'deviation (hereinafter "variance") from
adopted codes, ordinances or policies must be specifically requested in writing and be called out and identified. Processing
fees for such request shall be established by Council and shall be paid upon submittal and are non-refundable.
•
•`: Approval of any plat or plan containing provisions :which :do not comply with city code and for which a variance has not been.
specifically identified, requested and considered by the appropriate city official in accordance with the appropriate provision
of city code or state law does not approve any items not to code specification.
r Sound/Noise originating from temporary construction sites as a result of, construction activity are exempt from the, noise, limits
of ECC Chapter 5.30 only during the hours of 7:00amto'6:00pm on weekdays and 10:00am and 6:00pm on Saturdays, excluding
Sundays and Federal Holidays. At all other times the noise originating from construction sites/activities must comply with the
noise limits' of Chapter 5.30, unless a variance has been granted pursuant to ECC 5.30.120.
• Applicant, on behalf ofhis orher spouse, heirs, assigns, and successors in interests, 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 fromthe issuance for this permit. Issuance ofthis permit shall not be deemed to
modify, waive or reduce any requirements of any City ordinance nor limit in any way the City's ability to enforce any ordinance
provision.
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 TIME LIMIT: SEE ECDC 19.00005(A)(6);
" 121 1I1 r11Nf". 1111 1 FNC-'INFMtNC_ eAlq 1 771 _o "n FXT 1 i7f le I'D fAll 1 775-77?n
PUBLIC WORKS L425,) 1-0-2-35---T PRF TREA►TIYIFNT 4255 672-5755 1 RECYCLING X125 ,275-4801
F -Fire Final
CSO &CF) -03 $q
D1. V1.,1..OP.N11ENT SERVICES S R 2 0 2017
PLUMBING, MECHANICAL, TANK, & DEMOLITIO
PERMIT APPLICATION
12d 5°a" Avenue N, Edmonds, WA 95020
Phone 425.771.0220 4 Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): Parcel #:
N - ,..Ay
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ,.
Associated Permit #:
APPLICANT:Phone: Fax:
AddN � 'Slre.el, City, S (e�, Zip): E -Mail Address-
,
L715_.2.P0jhfqae>- ILL LLP
PR( 1ERTYOWNER: Phone: Fax:
Address Street, C"i Stale, p): Mail Adcl�
Zi E -Mail w k
`qty t %i c" N t.
[,ENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E -Mail Address:
CONTRACTOR:* Phone: Fax:
s_ _u
Address (Street, City, Vale, Zip): E -Mail Address:
WA State'LicV,e d /I xp, Dale:
*Contractor must have a valid City of Edmonds business license prior to doing work j� w
in the City. Contact the City Clerk's Office at 425.775.2525 City 13 ISHIe+,s i, ccitse #/Exp. Date:
PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK: A m._... ..._ ..... .- m_....m_. _..� w.... ...... . .. � ..
9
... ... ....._.. �W�__�)A.11.._.M. ulvn:
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a t
I declare under penalty of perjury laws that the information I have provided on this form/application is true, correct and complete,
and that I am the properly owner or duly authorized agent of the property owner to submit a permit application to the City of
Edmonds.
.� _ / . r ,t
Print Name: ~�„�,,,�, � Owner ❑ Agent/Other (specify): � p� � �M
Signature: e�......... Date: �.,,,�....�.._
FORM C L:1Building New Folder 2010U]ONE & x-ferred to L -Building -New driveTorm C 2014.doex Updated: 1/17/2014
TANK #1
Method of Abandonment
Fill in Place" Fill
Removal LJ
..�mm .
Number of Gallons _ _.._ .....
Critical Areas Determination:
�Study Required ❑
TANK #2
Method of Abandonment
" Fill in Place ❑ Fill Material.
Removal ❑
Number of Gallons
Conditional Waiver ❑ Waiver
Type of structure to he demolished (e.g. house, shed, garage, etc.):
Floor area of structure to be da:molished
Critical Areas Determination: Study Required
PSCAA Case No.
Additional comments:
Conditional Waiver Lj Waiver
AHERA Survey done? (required) ❑
ft.
FORM C LABuilding New Folder 2010\DONE & x-ferred to L -Building -New driveTorm C 2014.doex Updated: 1/17/2014