20050324.pdf1
DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
A 11,q
MAILING ADDRESS _
96663
CITY ZIP TELEPHONE
X125 lL cY55 J
NAME
ADDRESS
ADDRESS
CITY
ZIP I TELEPHONE
J PERMIT EXPIRES j&11105
ff
JOB SUI
PERMIT
Underground
NUMBERL-
ADDRESS f� q
TEIAPTu
Nye jlfg
AT NAME/SUBDIVISION NO. LOT NO LID NO,
LID FEE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApproved O
RW Permit Required 17
Street Use Permit Requited E3
EXISTING PROPOSED Inspection Requited O
Srdowelk Required 13
REQUIRED DEDICATION FT Willing required O
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
r,
YES I3 NO O z
W
tREMARKS w
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
W
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w
ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE w
LL
STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY I VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
REQ'D COMPLETED I EXEMPT
M YES ❑ NO
CA# ZONE SIGN AREA HEIGHT
PROPERTYTAXACCOUNT PARCEL NO.
2703/; WAIVER � ALLOWED PROPOSED ALLOWED PROPOSED
U d STUDY O
1:1 NEW RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR O
❑COMMERCIAL COMPLIANCE OR z
ADDITION ❑ CHANGE OF USE _
❑ MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE t a
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED i g
GRADING❑ FENCE REPAIR El ❑ ( X FT.) R NOjil S `� ' '
❑ DEMOLISH ❑ TANK 0 7L 2%i ti J"jt_ c
z ❑ RETAININGGARAGE WALL I FIRE
CARPORT ❑ ROCKERY ❑ FIREALARM LER
(TYPE OF USE, 8 (NESS OR AC VITY) EXP AI
j rte' Ji A TYPE OF CONSTRUCTION C DE GROUPANT
w NUMBER NUMBER OF
a OF DWELLING / SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES UNITS LOAD
to
0 REQUIRED 13YES -
DESCRIBE WORK TO BE DONE
REMARKS z
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GEOTECH REPORT
BY: m
STRUCTURAL DESIGN
BY:
VALUATION
$
Description =FEEDescription FEE
Plan CheckSurcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit JC%) City Surcharge
PLAN CHECK NO: ` Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO Mechanical
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC Gradin
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE g
SEPARATE PERMISSION.
� Engr. Review
w PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
IL PERMIT LIMIT: SEE ECDC 19,00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engf. Inspection
H •APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
w IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
i EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection 67) -� Receipt #
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE r�
o DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. TotrAmt,,Due� 3 S5
= NOR LIMIT IN ANY WAY THE CITY's ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee Receipt # Ell
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
GIVEN IS CORRECT; AND THAT 1 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• CALL Building Official or hislher Deputy: and Fees are paid, and
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 FOR INSPECTION receipt is acknowledged ui space provided.
WORKMEN'S CO ENSATION INSURANCE AND RCW 18:22 I LS SIGNATUIVE DA
s A RE ( 8R A(iENT)t DATE SI NED J (425) �25 0�
V, 771m0220 RE SED BY D E
ATTENTION EXT. 1333 _
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINA -FILE • YELLOW -INS ECT
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 I IBC110 if IRC110, PINK • OWNER • GOLD • ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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INSPECTION CHECKLIST
YES NO
Home licensed (or applying for license) on or after July 1, 2001 ❑n.
SLEEPING ROOMS ❑ ❑ .
Sleeping Room #1 ❑ S n NS 1 ❑ NS2
Bedroom door is openable from the outside when locked ❑ ❑
Closet doors are readily openable from the inside ❑ ❑
Smoke alarm is installed in the bedroom 0 ❑
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) ❑ 0
Sleeping room window has a maximum sill height of 44" ❑ ❑
Sleeping Room #2 0 S ❑ NSI 0 NS2 a'
Bedroom door is openable from the outside when locked 0 ❑ n
Closet doors are readily openable from the inside ❑ ❑ rn
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) ❑ ❑,
Sleeping room window leas a maximum sill height of 44" ❑ ❑ O rzrl
i Sleeping om #3 ❑ S 0 NS 1 ❑ NS2 m
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Bedroom door is openable from the outside when locked ❑ ❑ -� n
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Closet doors are readily openable from the inside ❑ ❑
1 Smoke alarm is installed in the bedroom ❑ ❑ Z
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) ❑ ❑ D
Sleeping room window has a maximum sill height of 44" ❑ ❑ Z
Sleeping Room #4 0 S 0 NSI 0 NS2
Bedroom door is openable from the outside when locked ❑ 0 CO)
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Closet doors are readily openable from the inside ❑ ❑
Smoke alarm is installed in the bedroom ❑ ❑ -1
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) ❑ ❑ m m
Sleeping room window has a maximum sill height of 44" ❑ ❑ cn
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Sleeping Room #5 0 S 0 NSI 0 NS2 O F
Bedroom door is openable from the outside when locked ❑ ❑
Closet doors are readily openable from the inside ❑ ❑ r Z
Smoke alarm is installed in the bedroom ❑ ❑ 'i
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) ❑ 0
Sleeping room window has a maximum sill height of 44" ❑ ❑ i
Sleeping Room #6 0 S ❑ NSI 0 NS2 z
Bedroom door is openable from the outside when. locked ❑ i --I
Closet doors are readily openable from the inside ❑ ❑ _
Smoke alarm is installed in the bedroom ❑ ❑ z
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 - ❑ ❑ m
GENERAL
Bathroom doors are openable from the outside when locked 0 ❑
Smoke alarms are installed on all levels of the dwelling ❑ ❑
All smoke alarms are audible in all parts of the dwelling upon activation of a single device ❑ ❑.
Access road and water supply approved by Fire Department ❑ ❑
0 CORRECTIONS RE
0 PASSED UIRED ❑ PERMIT REQUIRED Q
INSPECTOR:_. DATE:
i. ;
AUTHORIZED FOR RECORDING rn f '
City of Edmonds m Z
By: Dater C -1
Page I of 6
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WHEREAS the undersi ned owners of property located at �L¢(x'�
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in Edmonds, Washington legally described M.171
below or on the attached Exhibit A, have applied for a building permit for o
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compliance and/or to remodel a structure located on the site; and C 0
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WHEREAS, the applicant has notified the. City of applicant's intention to utilize the .-Z�
improvements and/or to convert an existing single family structure to an adult M
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family 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
conditioned on limitation of residents to (S or fewer residents and their
caretakers; and
WHEREAS, the City has issued a permit based upon such representations;
NOW, THEREFORE, 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 while providing notice to
any. future owners or. mortgagors of the property does hereby stipulate, covenant
and agree as follows:
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1. Covenant: Limitation on Residence. The owner hereby stipulates
and agrees that occupancy of the structure as an adult family home shall be limited
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 D residents or attempts to rent, lease or
otherwise provide residence for additional 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
covenant touches and concerns the land so long as the present structure and use
continues and shall run with the land to all future purchasers and assigns.
2e Subject Tract. The above stipulation and promises shall apply to and
run with the land with respect to a residential structure located at q1POQ 0
Edmonds, Washington and legally described as: p
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3. Notification to Future Purchasers and Assignees. This notification ; z
and covenant has been recorded in the records of Snohomish County, Washington gOWNED
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in order to 'provide notice to any and all future owners of the property of the N
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limitation at the current level of improvement to single families and adult family o
home residents fewer than,_ in number.
M.
40 Enforcement. In addition to any and other remedies civil or criminal
OPINIONS
which the City may have, the property owner hereby agrees and stipulates that this
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's fees and costs.
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• � h�:,i n
DATED this day of ` f,l• 20 r
ACCEPTED BY; A PLICANT/PROPERTY
OWNER: r...._.
Applica t s
Jeannine L. Applicant
Building Official
Owner
Owner
COVENANT AND z
NOTIFICATION0.
ACKNOWLEDGED: m
1p
Mortgagor0 _
NOTARY FOR OWNER SIGNATURES m v
State of Washington ) o n
)ss -�
County o .... ` m Z
I certify that I know or have satisfactory evidence that i�'-' D Z
signed this instrument, on oath stated t t h she w aut orized to exec t th _
'nstrument and acknowledged it as the • (title) of
•J / (Mn
name of party on behalf o 'whom instrument was executed) to be mn
the fr a and voluntary act of such party for the uses and urposes menti 'ns in this _
instrument. Subscribed and sworn to before me this ' , day of m m
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NoMry Pu tic. C m
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ssft of wash 1
xAY L vuElL.IUUGN�t� to
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Notar lic i a fo�.the State of W hlh'0oii:'itmant Fxplfes Sup T.2UUU r
My commission ires. �� ;a
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I certify that`I know or have satisfactory evidence that ^' �I.�
� �I ti � r Z
signed this instrument, on oath stated that he/she was authorized to execute the i
'nstru ent and acknowledged it as the ft Inc � (title) of
•I (name of'party on behalf on whom instrument was executed) to be Z
the f e and voluntary act of such party for the uses andyurposes mentions in this MMI
instrument. Subscribed and sworn to before me this _ day of • l m
Nota Pu lic i and fo6th State of Washington.
relym is 'o expires i
AUTHORIZED FOR RECORDING
.c�f;�rY t~iibtia; I
City of Edmonds ;,7;'ltoofMtlshInrrcn i.
By: Date: ; 'AM17:jY1 1n't �i rsa a 7t:�i '
Page j_ of 7,
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