ESLHA PERMIT APPCity of Edmonds
Completeness Review Pre -Application Form for
Earth Subsidence Landslide Hazard Area projects lac 1g9a
Notice: This is not a Building Permit Application Form. This is Step One of a two-step process (see
Earth Subsidence Landslide Hazard Area Permit Submittal Checklist for description of the complete
application process) The Completeness Review is a preliminary process to determine that minimum
submittal requirements have been provided for the geotechnical and critical areas elements of the
Earth Subsidence Landslide Hazard Area Permit Submittal Checklist. If it is determined that
additional information is required to be complete, the applicant will be notified in writing of the
deficiencies and must resubmit for another completeness review (including fee of $500). This
process continues until the applicant is notified in writing that the Completeness Review is accepted
by the City consultant and may proceed to Step Two, Building Permit Application Submittal.
Completeness Review Application for: ❑ New Single Family ❑ Addition
❑ Interior Remodel ❑ Garage/Carport ❑ Repair EQ Deck
❑ Fence ❑ Grading cods ❑ Storage/Shed
❑ Fire System (Specify) ❑ Rockery/Retaining Wall
❑ Other (Specify)
Description of Work: �cl,�sn N 5 F . a . M Ig i N - ►Fwo 12 R.�-YnopE1 . Li (aW sF rA rC H N r LU()f
140011 01"Q, �Tgq.-- ',-�F WiT�p�' , iOZ) .l SF Ui�pt'� F� e�gr2 ,�►�iTla�j
co -To 'Sp `D�,1� AY�!'7i�sl�N
Site Address: 1329 1543 -ni s i SW 5&YIONOS pya �3o2h
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Sno County Tax Account Parcel #: ',A oT `I U fi n �� N -t-�1D
PROPERTY OWNER: S I-} 191Q o N A 9 9 SE N
Mailing Address: °J g 3 Z M lq rz I N S V I f W D 12
City: M 1.1 I_l L TAD State: Yv i Zip. 9 g 2--T S
5H rit2oN L.Pg1aS4a-0
Phone: (U 2 5 ) 3141 " l Lf 5 1 FAX: ( ) E-Mail: F 12 vac-)11- t2 . Co M
APPLICANT/CONTACT: ❑Same as Property Owner Other
Fill out the following information if "Other". Z 3oZ d
�EDMONQ5
Name & Mailing Address: L ISF) M 0 N'T1P LU t> (,N- W RPC,+41 TtGTZu2lF --' 0-pS i4N) W 4# 1) 3
City: EbhIna.NbS State: I.Jr+ Zip: 4b626
Phone: (Lb lo) 5� 3 3''-I FAX: ( ) E-Mail: 1,I91 ): e H 210.19 PtH )T TTS,
com
5/21/2018 Packet Item # 3
City of Edmonds
DEVELOPMENT SERVICES
ESLHA BUILDING CHECKLIST
121511 Avenue N, Edmonds, WA 98020
Phone 425.771.0220 0 Fax 425.771.0221
PROJECT ADDRESS: 13Z I .TH 5r �5(t)
Plans shall be of sufficient clarity to indicate the location, nature, and extent of the work proposed, and conform to the provisions of
the adopted International Codes and City Ordinances.
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SUBMITTAL REQUIREMENTS
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Pre -Application Form
1
1
1
1
1
1
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Application Form F
1
1
1
1
1
1
Critical Areas Study Document (if applicable)
4
4
4
4
4
1\
ESLHA Map w/signature block (1 original)
3
3
1 3
3
3
3
Topographical Map and Survey
4
4
4
4
4
Vicinity Map
4
4
4
4
4
4
Site Plan
4
4
4
4
4
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Lead Design Professional Designation and
3
3
3
3
3
Statement (1 original)
Applicant/Owner Liability & Landslide
3
3
3
3
3
3
Acknowledgement (1 original)
Geotechnical Hazard Identification/Declaration &
Mitigation Statement of Risk from Geotechnical
3
3
3
3
3
Engineer and Civil Engineer of Record (1 original)
Structural Engineer Declaration (1 original)
3
3
3
3
3
3
Applicant/Owner Covenant to Notify & Hold
Harmless (1 original)
3
3
3
3
3
3
Building Construction Plans (structural plans
stamped by Structural Engineer)
3
3
3
3
3
3
Structural Calculations
3
3
3
3
3
3
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Energy Code Compliance (shown on plans)
✓
✓
✓
✓
Site Classification Worksheet (storm water)
✓
✓
✓
✓
✓
Civil Plans (Grading, Storm Drainage, TESC, Utilities)
3
3
3
3
3
stamped by Licensed Engineer
Right -of-Way Permit Application
✓
✓
✓
✓
✓
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Geotechnical Report
4
4
4
4
4
Land Clearing/Tree Cutting Plan
4
4
4
4
4
Affidavit of "Notice of Application Posted at Job Site
1
1
1
1
1
Washington State Contractors License
✓
✓
✓
✓
✓
✓
Contractor's City of Edmonds Business License
✓
✓
✓
✓
✓
✓
Plan Check Fee (due upon submittal)
✓
✓
✓
✓
✓
✓
SEPA (grading, fill, excavation > 499 cyds.
✓
✓
✓
✓
✓
✓
Updated: 12/2017
Peer Review Fee
✓
✓
✓
✓
✓
✓
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submittal (if applicable). Check marks indicate
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additional submittal requirement
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Administrative Review Fees
✓
✓
✓
✓
General contractor Public Liability Insurance
✓
✓
✓
✓
✓
✓
• Handouts and Standard Details may be found on the City's website www.ci.edmonds.wa.us or can be obtained at City Hall
during normal business hours.
• Plans/calculation/reports prepared by state licensed architects or professional engineers must be stamped and signed by
the design professional.
• Seasonal Construction Period: limiting all excavation and drainage installation to the drier season (normally between May
Vt and the end of September).
• During all work periods special inspections shall be performed after storm events as defined in ECDC 19.10.020(0).
• The Geotechnical Engineer shall make written, dated, reports on the progress of the construction and submit the reports to
the Building Official on a weekly basis until all site grading, drainage, foundation and associated ground work is complete.
• At the completion of final site grading and all permitted structures, a final geotechnical report, prepared by the
geotechnical engineer of record, shall be submitted to the Building Official.
Updated: 12/2017
4 OV DAfO
st 18g�
City of Edmonds
Equipment Type
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION FORM F
12151h Avenue N, Edmonds, WA 98020
Phone 425.771.0220
MECHANICAL
Appliance/Equipment Information (new and relocated) Total #
Furnace
#Gas #_Elec #_Other: BTUs: <100k >100k_ Location
I
Air Handler/AC/VAV
#_Gas #_Elec #_Other: CFM: <100k_>100k_ Location
Boiler/Compressor/ Heat
Pump/Roof Top Unit
#_Gas #_Elec #_Other: BTUs: <100k, 100k-500k, 500k-1Mil
HP: <3, 3-15, 15-30 Location
Hydronic Heating
#_Gas #_Elec —in-Floor, _Wall Radiant, Boiler BTUs: Location
Exhaust Fans (single duct)
Location: #_Bath #Kitchen # a Laundry # Other:
Fireplace
# I. Gas #_Elec #_Other: Location
Other
Number of Outlets Fixture/Appliance Type
AC Unit ----------- BTUs: Location:
1
Furnace ------------- BTUs: Location:
i
Water Heater --------BTUs: Location:
Boiler -----------BTUs: Location:
Fireplace/insert BTUs: Location:
0
Stove/Range/Oven:
Dryer
Outdoor BBQ:
Other:
5 TOTAL OUTLETS
COUNTPLUMBING FIXTURE
Number Fixture Type Number Fixture Type
Water Closet (Toilet)
Refrigerator water supply (for water/ice dispenser)
Sink (kitchen, laundry, lavatory, bar, eye wash, etc)
Water Service Line
j
Tub/Shower
Drinking Fountain
Dishwasher
Bidet/Urinal
Hose Bib
Pressure Reduction Valve/Pressure Regulator
Water Heater Tankless? Yes_ Nax—
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Expansion Tank for Water Heater
Hydronic Heat in: Floor Wall
Floor Drain/Floor Sink
Other:
Clothes Washer
Other:
Updated: 12/2017