16508 75TH PL W16508 75TH PL W
FOiL\1 FOR /rijv .] DE-cu zATION OF r,5tetfff IfWiWINONSIGNIFICANTCE)
Description of proposal S l h1 l., T:'A1M.1 1,'�1-1-J
Proponent PQ U L VD 'RL a0 nD 2 l C�X_
Location of Proposal f ps l D f' LA LE -
Lead Agei icy L? d %'Y1 p rA QIz , E!)Lk 1 L7 j N Ge_ .►- Ply N 114k
Ix I S
Ihis proposal has been dci:ermi.ned to H*-Ree/not have] a sig i.fic:.�nt ad-
verse im-puct upon -the envirormcnt: An EIS [4--,,/is not] required under
101 43.21C.030(2) (c) . 11hi.s decision was made after rcview by t?ie lead
agency of a completed enviro::r ental checklist and other infoi-cation on
file with the lead agency..
Responsible' Official Mtk f Lu LA. 6LD CAe
Position./Title 4":&SDC-1 tz-
Date Cr g Signature` �j
0
4.. P. 78030 1
pROJECI' P�Ar1E lJ��e plfC� ` �S /,LAN
DATE SUBMITTED
ENVI RO:J:IEiaTAL ASSESSMENT
:In order to meet the requirements of,the.State Environmental Policy Act of 1971,
the responsible official must make a declaration of environmental impact as early
as. possible in the process of evaluating a project.
The information in this form vjill be used to determine %ghether it will be necess-
ary to require an environmental inoact statement. If 'an impact statement 'is
not required, a Statement of Negative Declaration will be placed in the file.
If an impact statement is required, a draft statement must be filed with this
-office, oublic notice given and a reviela period of 30 days allowed. The final
.statement and comments must be filed with the Department of Ecology, Office of
the Governor and tie. Ecological Commission.
The Edmonds Planning Staff will assist you in any way we can in accumulating
-this information and ae would appreciate .your cooperation.
1. Land:
Area in acres
.Soils type L i . Limitations
Description of topography (% slope) /� — /3 /
Grading: estimated cubic yds. /i/ 4 /y NOTE: If grading or filling
will exceed 500 cubic yards
Filling: estimated cubic yds. _de n/ a grading and filling plan
must be submitted with the
2. Water: application.
Stream - estimated flow (cubic feet per second) N 0 N ie
lJill stream be altered? /Y 0/Y£
To what degree?
Impact on storm drainage (increase in run-off) /u OWE
Estimated area .to be paved /00 %���U h
Estimated area in open space
Shorelines: within 200 ft. of Mean higher Nigh dater �Qy�
Adjacent to shorelines zone
j
..:..Environmenta l Assessment, page 2
3. `Vegetation
Type of trees �y S to be removed
Minimum diameter of trees to remain'
Ground cover �SCd��ys % to be removed
- Proposed landscaping, 'if any is
4. Existing Land Use within 300 ft. radius of proposed development:
Vacant
Single
Family
MUIti-
Family
Comm.
Other
North
South
East
West
5. Circulation:
Estimated increase in auto trips daily
Estimated demand for public transportation'%
Degree of change on adjacent streets 40
6. Area of impact: /
neighborhood
city-wide
regional
7. .Effect on air quality:
r
8. Changes in noise generation: , �,�
2
3
41
51
6'
7
9'
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59
60
DATE:
A $25 fee will be collected by.the City of Edmonds for analysis
of the Environmental Checklist and the preparation of a Threshold
Determination. No'fee will be charged for proposals which would
be categorically exempt if they were not located in an environ-
mentally sensitive area.
ENVIRONI-IENTAL CHECKLIST. FOR%I
I. BACKGROU14D
1. Name of Proponent
2. Address and Phone Number o Prop nent:
3? 410 At
3. Date Checklist Submitted�
4. Agency Requiring Checklist
5. Name of, Proposal, if applic e: ,
6. Nature and Br et Description o the Proposa inc uT-
ing but not limited to its size, general design ele-
ments, and ocher factors that will pi.ve an accurate
understandinof its scope an��11 natu� e)
U / G-I� f�•- �/U-� . Sty
7. Location of Proposal uescri e L e piysicaT setting of
the proposal, as well as the extent of the land area
affected by any environniental impacts, including any
other information n.eeded to give an accurar-, understand-
ing of the envi nmcntgl settin of the proposal):,
8. Lsti.mat—lee llat or Comp etior of the Propose Action:
9. l.i.sst= o . all Permits, Lic hses or Government Approvals
Required for the Proposal (federal, state and local --
including rezones):
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1�
3
4
5
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60
61
62
63
64
65
66
10. Do i have'any plans for future ad*ons, expansion,
or further activity related to or connected with this
proposal? If yes, explain:
11. Do you nova of any plan y others which may affect
the property covered by your proposal? If yes, explain:
12. Attach any other application Corm that has been com-
pleted regarding the proposal; if none has been com-
pleted, but is expected to be filed at some future
date, describe the nature of such application form:
II. ENVIRONIMENTAL IMPACTS
(Explanations of all "yes" and "maybe" answers are
required)
• Yes Maybe No
(1) L•'arth. Will the proposal result in:
(a) Unstable earth conditions or in
changes in geologic substructures?
(b) Disruptions, displacements, com-�
paction or overcovering of the soil?
_
(c) Change in topography or ground
surface relief features?
(d) The destruction, covering or
modification ofany unique geologic
or physical features?.
(e) Any increase in wind or water
erosion of soils, either on or off
%
the site?
7/
(f) Changes in deposition of ero-
sion of.beach sands, or changes
in siltation• deposition or erosion
which may modify the charnel of a
river or stream or the bed'oP the
/
ocean or any bay, inlet or lake?
!/
Explanation:. S1M9kE 'FAQ1,j LY
OWMAJ. I N fr &ISU'�P A5C IX1 FW,6,V
(2) Air. Will the proposal result in:
(a) Air emissions or deterioration ,
of ambient air quality? v
(b) The creation of objectionable
odors?
(c) Alteration of air movement,
moisture or temperature, or any /
change in c'imate, either locally
or regionally? vvv
Explanation:
-32-
•f'
1'
2�
3
4
.61
7'
8i
9•
10�
1Zi
12i
13i
14
15
161
17'
18'
191
I
21
22
2311
24
251
26,
27I
28
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30
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40
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42
43
44
45
46
47
48
49
50
51
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53
54
55
56
57
58
Yes Maybe No
(3) Water. Will the proposal result in:
(a) Changes in currents, or the
course or direction of water move-
ments, in either marine or fresh
waters?
.(b) Changes in absorption.rates,
drainage patterns, or the rate and
amount of surface water runoff?
(c) Alterations to the course or
flow of flood waters?
fj
(d) Change in the amount of sur-
face water in any water body?
(e) Dischar.Ee into surface waters.,
or in any alteration -of surface
water quality, including but not
limited to temperature, dissolved
oxygen or.turbidity?
(f) Alteration of the direction
or rate of flow of ground waters?
(g) Change in the quantity of
.ground waters, either through
direct- additions or withdrawals,
or through interception of an
aquifer by cuts or excavations?
/
L/
(h) Deterioration in ground water
quality, either through direct in-
jection, or through the seepage of
leachate, phosphaucs, detergents,
waterborne virus or bacteria, or
other substances into the ground
/
waters?
!/
(i) Reduction in the amount of
water otherwise available for
public water supplies?
Explanation:
(4) Flora. Will the proposal result in:
(a) Change in the diversity of
species, or numbers of any species
of flora (including trees, shrubs,
grass, crops, microflora and
aquatic plants)?
(b) Reduction of the numbers of
any unique, rare or endangered
species of flora?
-33-
Yes
Maybe: No
1
(c) Introduction of new species
2)
of flora into an area, or in a
3I
barrier to the normal replenish-
/
4
ment of existing species?
5
—
6
(d) Reduction in acreage of any
7
agricultural crop?
v
8
,
9
Explanation:
10
11
12
(5)
Fauna. Will the proposal result in:
13
14
(a) Changes in the diversity of
15
species, or numbers of any species
16
of Fauna (birds, land animals
17
including reptiles, fish and shell-
18
fish, benthic organisms, insects or
j
.19
microfauna)?
f/
20
---
— —
21
(b) Reduction of the numbers of.
22
any unique, rare or endangered -
23
species of faunal
24
—
— —
25
(c) Introduction of new species
26
of fauna into.an area, or result
27
in a barrier to the migration or
/
28
movement of fauna?
2.9
—
— —
30
(d) Deterioration to existing
31
fish or x•jildlife habitat?
L/
32
—
=--
33
Explanation:
34
—
35
36
(6)
]doise. Will. the proposal increase
37
existing noise levels?
38I
—
39
Explanation:
40
41.
42
(7)
Light and Glare. 14,•11 the pro-
43
posal pruciuce new light or
44
glare?
45
—
— —
46
Explanation:
47
48
49
(8)
Lind Use. trill the proposal
50
r'esu t In the alteration of the
51
present or planned land use of an
52
area?
Y
53
---
--- —
54
Explanation:
55
-
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YesQ�beNo
1
2
(9) Natural Resources. Will the pro-
jiOs.zT resulL+1-'nc
3
..
4
5
(a) Increase in the rate of use
1 6
of any natural resources?
7
8
(b) Depletion of any nonrenewable
natural resource?
9
10
Explanation:
11
12
13
14
(10) Risk of lipset. Does the proposal
i vn olve
15
a risk of an explosion or
the release of hazardous substances
16
17
(including, but not limited to,
18
oil, pesticides, chemicals or.
19
radiation) in the event of an acci-
dent upset
e /
20
or conditions?
21
Explanation:
22
23
_
24
25
(11) P_opuulaat.ion. Wi.l.l the proposal
26
a tl el t}ic location, distribution,
27
density, or growth rate of the
human population of
28
an area?
29
Explanation:
30
31
32
33
(12) tiousin�. Will the proposal affect
34
existing; housing; availability, or
35
create a demand for additional
36
housing?.
37
38
Explanation:
—
39
---
40
41
(13) Transportation/Circulation. [dill
Te proposare42 n:
43
44
(a) Cenerati_on of additional
45
vehicular movement?
46
--
—
47
(b) Effects on existing parking
facil.i.ti.es,
48
or demand for new
parking?
49
50
51
52
----
Impact upon existing; trans-
portaL-i.on systems?
-- v
53
54
(d) Alterations to present
--
55
patterns of circulation or inove-
56
ment of people and/or goods?
57
58
(e) Alterations to waterborne,
rail or air traffic?
1
3
4�
5
6
7
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23
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.34
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39
401
41i
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
Yes
Maybe '20
(f) Increase in traffichazards
to motor vehicles, bicyclists or
,
pedestrians?
Explanation:
(14) Publi.c Services. Will the pro_
posal-Tiave an effect upon, or
re:;ult in a need for .new govern-
mental services .in any of the
following areas':
(a) Fire protection?
_
(b) Police protection?
(c) Schools?
(d) Parks or other recreational
facilities?
—
(e) Maintenance of'public facili-
ties, including roads?
_ v
(f) Other governmental services?
Explanation:
(15) Encr Will the proposal result in:
(a) Use of substantial amounts of
fuel or energy?
(b) Demand uponexisting sources
of energy, or require the develop-
ment of new sources of energy?.
Explanation:
(16) Utilities. Will the proposal
resiTt i.n a need for r..-,vstems,
or alterations to the following,
utilities:.
(a) Power or natural gas?
(b) Communications systems?
v
(c) Water?
(d) Sewer or septic tanks?
(e)_ Storm water drainage?
'
(f) Solid. waste and disposal?
v
t:xpl.anation: (�` (il�CL1
-36-
Ybs Maybe No
1' (11) 11ui;�tn 110OLth. Will the pcc)posal
2 � resul�l
t e creation of any
• <
I health hazard. Or potential health
41 hazard (excluding mental health)?
5. _
6 Explanation:
7I
8
1 9 (18) Aesthetics. Will the proposal
10 result 1n the obstruction of any
111 scenic vista or view open to the
12' public, or will the proposal re-
13, sult in the creation of all
14 aesthetically offensive site open
15 to public view?
16
17 Explanation:
18
19
20 (19) Recreation. Will the proposal
21 restilL in an impact upon the
22 quality or quantity of existing
23 recreational o /
24 opportunities?
25 Explanation.
26
27
28 (20) . ArchoolML—i-I ./Ili.stori.cal . Will the
29 proposa rOSU t i.n an alteration of
30 a significant archeolol;ical or his-
torical torical site, structure, object
32 or building?
33
34 Explanation:
35
36
37 III. SIGNATURI:
38
39 I, the undersigned, state that to the best of my knowledge
40 • the above information is true and complete. It is understood
41. that the: lead af;cncy may withdraw any It
of non-signi-.
42 ficance that it might issue in reliance upon this chccicli�t
43 should there be any misrepresentation or lac f full disclosure
44 on my part.
47 G2 C
�i6 Proponent
47
48 WAC 197-1.0-370 WITIiDRAI-ML OF AFFIRMATIVE THM'SIIOLD
49�,1`I'10ti. 1t atly time after the etltry of a declara-
50 tion of siF,nificance, the proponent modifies t:he proposal
51 so that, in the judgment of the lead al;eticy, al.l si�ni.ficatlt
52 adverse environruentai. impact:s resultin, therefrom are f icantClimin-
53 aced, the decideclaration
of siF;nific.ancc ^hall be withdrawal
54 and a declaration o[ non-s _
55 lead agency shr117. also reviselthe1regisncc ters`�Clits`SIPA The
56 public information center accordingly.
57 poncnt of a proposal. i.s a private aplicant, therpl"oposal
58 shall not be considered modified until al.l license appl.ica-
54 tions for the prop1 osal are revised to reflect the modification.
-37-
PUBLIC WDRKS DEPARTMQVT CHECKLIST itf to ~ Date
BUILDING PERMIT REVIEW STREET FILE �rI % , PAddress
Street Right -of -Way Existing
Access Easements Existing _
Utility Easement Exist' N( -)
Lot per Subdivisiont4i Plat
Site Plan Checked for Accuracy
Underground Wiring Reqd.
Check Accuracy of Legal Description _
Environmentally Sensitive Area
Environmental Checklist Reqd.
Flood Hazard Zone
Shoreline Management Area
Slope, Soil, Vegetation
Stream, Creek, Drainage P
Existing Zoning Per Code
REQD
REQD
REQD
Assessor
Amenities Design Board Approval Reqd. ADB #
Board of Adjustme Approval Reqd. kip VC0
Review By 0 1� Date:
Existing Water 'Main Size e5
Water Main Reqd. p,C
Service Line Reqd.
Hydrant Size Existing gD4
Hydrant Reqd. Per Fire Code It --)A Size
Detector Check Meter Reqd. .t%O
Cross Connection Inspection
Fire Department Cozmients
Water Meter Charge Rem
Review by: Date: G�
�--- Approves
Septic Tank Design Approved Date:
Septic Tank Permit Reqd. Es. Permit No.
Sanitary Sewer Availabili �4 Proj.
Drawing No. File No.
Side Sewer Availability CO
0
Sanitary Sewer Connection Fee Reqd.
Review By: _ Date:
BUILDING DEPARTMENT
USE PERMIT
ZONE
Applicant Fill
V5_ `� NUMBER
1
PERMIT APPLICATION
Inside Heavy Lines
,QB
ADDRESS!! ` 5--
'
NAME (OR NAME j9F BUSINESS)
SUBDIVISIONrIN�O�/
LAT NAME
MAP NO.
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JASSESSOR
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MAILING ADDRESS
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PUBLIC RIGHT OF WAY PER ORDINANCE NO.
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EXISTING RIGHT OF WAY/
CITY j
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TELEPHONE
EL ��EffP H/ONE NUMBER
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PROPOSED RIGHT OF WAY
NAME
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DEFICIENCY OF RIGHT OF WAY
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ADDRESS
STREET/UTILITY WORK REQUIRED ❑YES S:NO
Y
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UPERMIT
FOR WORK IN PUBLIC R/W DYES 111NO
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CITY
TELEPHONE NUMBER
K
Q
UNDERGROUND WIRING REQUIRED 12Y ES El NO
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CONNECTION TO SANITARY SEWER El YES IRNO
SEPTIC TANK PERMIT REQUIRED YES ❑NO
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NAME
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SEPTIC TANK PERMIT NO. / C J— J ./ 1
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ADDRESS /J
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SEE MEMO DATED (6 )I^ 1-•��
CITY ;�
TELEPHRN NUMBER
REMARKS
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STAT LICENSE NUMBER
CITY LICENSE NUMBER
CHE KE
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Leg.Al gescry,ion-of Prop rty (Show Below or Attac Four Copies)
METE Iz BUILDING SUPPLY SIZE
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PIiE�SV2E RE6C)L_0,10ft. (RE4&u .
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SIGN AREA
ENV. REVIEW
ADD NO.
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ALLOWED, PROPOSED
COMPLETE EXEMPT
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REMARKS
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VARIANCE OR Cu
PLANNING REVIEW BY
DATE
YARDS
LJ FRONT (of ��
LOT COVERAGE
NEW RESIDENTIAL GAS
. SIDE REAR
FIRE ZONE
TYPE OF CONSTRUCTION CODE
HEIGHT
LINE
❑ ADD ❑ NON-RESIDENTIAL SIGN
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A { 3
:30'mA
❑ DEMOLISH ❑ RETAINING
WALL
SPECIAL INSPECTOR
REQUIRED
AREA
OCCUPANCY OCCUPANT
ALTER EXCAVATE FENCE
❑ OR FILL ❑ X
❑ (
❑ YES NO
GROUP ..{{�� LOAD
CHECK O BY THIS SITE IS LOCATED IN THE CITY
OF EDMONDS. LOCAL SALES
_FT)PLAN
PRE -MOVE swim
REPAIR El INSP. POOL
TAX
- SHOULD BE CODED 31.04.
NUMBER OF STORIES
NUMBER OF j
REMARKS
DWELLING .
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UNITS
W
NATURE OF WORK TO BE DONE
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PLAN CHECK FEE
VALUATION
FEE
PROPOSED USE
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PLOT PLAN INDICATE BUILDING SETBACKS,
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ABUTTING STREETS)
BUILDING
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PLUMBING
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MECHANICAL
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FENCE
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RETAINING WALL
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SWIMMING POOL
� STREET FILE -
MEMO TO:
FROM
SUBJECT:
DATE: S ! 3 ( -VR
Building Division
Community Development Department
Engineering Division
Public Works Department
T_R Pam-
After review of the subject building permit application, we have
the following comments:
(1) Coordination of the location of any structure with respect to
utilities, streets, property lines and driveway grades is the
responsibility of the contractor.
(2) The contractor is required to keep the abutting streets clean-
ed of dirt an e ris caused by, the construction.
(3) A "Right -of -Way Construction Permit" is required, from the
Engineering Division of Public l+'orks, for any work within
the Public Right -of -Way or public easement.
(4) Driveway slope not to exceed 140.
(701 - tea►. - r. .mot W r-2-0
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PW 5/77