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CONSTRUCTION PERMIT APPLICATION
OWNER AAIE NAME OF USINESS
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Plan Check No. C 7
MECHANICALThis
Permitcovers work to be done on private property ONLY.
GRADINGIFILL
111E
Any construction on the public domain (curbs, sidewalks,driveways,
marquees, etc.) will require separate permission.
STATE SURCHARGE
Permit Application: 180 Days ,'POrmil
STORM DRAINAGE FEE••Applicant,
Limit: 1 Year - Provided Work is Started Within 180 Days
on behalf of his or her spouse, heirs, assigns -and
ENG. INSPECTION FEE
successors in interest, agrees to Indemnify, datendandh01dharmless
City Edmonds, Washington, its officials,
the of
and agents from any and all claims for damages of
� 1,6 ,i
remployees, t ,
whatever nature• arising directly or Indirectly from the issuance
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s of this permit. Issuance of this permit shall not be deemed to
PLAN CHECK DEPOSIT
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1.
° modify, waive or reduce any requirement of any city ordinance
° nor limit in any way the City's ability to enforce any ordinance
TOTAL AMOUNT DUE
nnI
provision."
I hereby acknowledge that I have read this application; that the
APPLICATION APPROVAL
information given is correct; and that I am the owner, or the duly
ATTENTION
authorized agent of the owner. I agree to comply with city and
THIS PERMIT
state laws reg ulet l ng construction; and lndoing theworkau thortz•
AUTHORIZES
This application is not a permit until
Ed thereby, no person will be employed In violation of the Labor
ONLY THE
signed by the Building Official or his/her
Cod of the Stake of Wasl]ington relating to Workmen's Compensa•
wOAK NOTEo
Deputy; and fees are paid. and receipt is
tion Insurance d RCW IB.Z7.
INSPECTION
acknowledged in space provided.
SIGN RE IOWNE R AGENTDATE SIGNED
DEPARTMENT
CITY OF
0 F CIAL S IGNATURE DATE
'J� !y .' �-'� I� '. •�
4
EDMONDS
ATTENTION
CALL FOR
INSPECTION
RELEA DATE
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,
IT IS UNLAFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
.. /�
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED. USC
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oCITY CLERK
CITY OF EDMONDS
505 BELL STREET
EDMONDS, WA 98020
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H' NOQaA,
COVENANT OF NOTIFICATION AND INDEMNIFICATION/HOLD HARMLESS
Under the review procedures established.pursuant to the State
Building Code, incorporating amendments promulgated by the City.
of Edmonds, and as a prerequisite to the issuance of a building
permit for the construction of a residential structure and
attendant facilities, the undersigned OWNERS of property do
hereby covenant-, stipulate and promise as follows:
1. nesc _pticr cf s,--j ct 'p- ^er This cotenant of
notification and indemnification/hold harmless relates to a tract
a� �ata
of land at the street. address. of (insert
street address), Edmonds, Snohomish County, Washington and
legally described as:
2. Notification and Covenant of Notification. The above
referenced site '(hereinafter "subject site") lies within an area.
which has lieen identified by the City of Edmonds as having a
potential for earth subsidence or landslide' hazard. The risks
associated with development of the site have been evaluated by
technical consultants and engineers engaged by the applicant as a'
part of the process to obtain a•building permit for the subject
site. The results of the consultant's reports and evaluations of
WSS52079A/0006.040.034 -I-
WSS/klt 02/08/90
J
C�7
VOL. 315 9 PACE 2 5 5 8
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32XIE
No
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161
the risks associated with development are contained in building
permit file number �%�(insert number) on file with the
City of Edmonds Building Department. Conditions, limitations, or:
prohibitions on development may have been imposed in accordance.
with the recommendations of the' consultants in the course of
permit issuance. The conditions, limitations, or prohibitions
may require ongoing maintenance on the part of any owner or
lessee or may require modifications to the structures and earth
stabilization matters in order to address future or anticipated
changes in soil or other site conditions. The statements and
conditions proposed by the OWNERS' geotechnical engineer,
geologist, architect and/or structural engineer are hereby
incorporated by reference from the contents of the file as fully
as if herein set forth. Any future purchaser, lessee, .lender or
any other person acquiring or seeking to acquire an interest. in
the property is put on notice of the 'existence of the content of
the file and the City urges review of its contents. The file may
be reviewed during normal business hours or copies obtained at.
the Planning Department, City of Edmonds, 505 Bell Street-,
Edmonds, Washingtan 9S020.
3. Indemnification and Hold Harmless. The undersigned
OWNERS hereby waive any and all liability associated with -
development, stating that they have fully informed themselves of
all risks associated with development of the property and do'
therefore waive and relinquish any and all causes of action
against the City of Edmonds, its officers, agents and employees.
WSS52079A/0006.040.034 -2-
WSS/klt 02/08/90
59PAGE 2559
32X C
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arising from and out of such development. In addition, the
OWNERS on behalf of themselves, -their successors in interest,
heirs and .assignees, do hereby promise. to indemnify and hold
harmless the City of Edmonds, its officers, agents and employees
from any loss, claim, liability .or damage of any kind or nature
to persons or property either on or off the site resulting from
or out of earth subsidence or landslide hazard, arising from or
out of the issuance of any permit(s) authorizing development of
the site, or occurring or arising out of any false, misleading,
or inaccurate information provided by the OWNERS; their
employees, or professional consultants in the course of issuance
of the building permit.
4. Insurance Reouirement.. In addition to any bonding which
may be required during the course of development, the Community
Services Director has/* Vt (strike one) specifically required
the maintenance of an insurance policy -for public liability
coverage in the amount and for the time set forth below in -order
to provide for the financial responsibilities established through
the indemnification and hold harmless agreement above:
� o.✓c �/!/�u.,� do/%r.t.-Plib/�c ls!i/ � ��►�rt.�r.9.vt.��s&�/I J,a1 .
�i►.d m11/,vf�iyd Curry ZOifl lle Cry1:5;L.4 lGd- Hof
(insert insurance requirements and time.period,
WSS52079A/0006.040.034 -3-
WSS/klt 02/08/90
9605080387 VOL.3159PAGE2560
10
32X I I
S. Covenant to'.Touch and Concern the Land. This covenant
I
of notification and indemnification/hold harmless touches and
concerns the subject tract and shall run with the land, binding,
obligating and/or,inuring to the benefit of future owners, heirs;
successors and interests or any other person or -entity acquiring
an interest in property, as their interest may appear: This
provision shall .not be interpreted to require a mortgagor or
lender to indemnify the City except to the extent of their loss
nor to obligate such persons to maintain the insurance above
required.
DONE this•
day of • _ ,. 1995. x
i r 3
d
OWNER(S)
By: A&t.,.J .D .
By.
i
By:
f
• i
STATE OF WASHINGTON ) I
ss:
COUNTY OR_'&�J )
I certify //that I know or have satisfactory evidence j
thataLQAJ �Ll(�_ signed this' instrument and acknowledged'
WSS52079A/0006.040.034 -4-
WSS/klt 02/08/90
9605080387 VOL. 3159P&sE2561
o •
32X E
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it to be (his er) free and voluntary act for the purposes
mentioned in this instrument.
DATED this day of 1g9�
M commission ex y0
Y'� Aires: �'• i
STATE OF WASHINGTON
COUNTY OF )
I certify that I know or have satisfactory evi'Aehi e
that signed this instrument and acknowledged
it to be (his/her) free and voluntary act for the purposes
Lo
mentioned in this instrument_01
o
- 3
DATED this day of 199_.
1 i
m
NOTARY PUBLIC c a
My commission expires: I
STATE OF WASHINGTON ) I'
xo, N
ss: a
COUNTY OF )
I certify that I know or have satisfactory evidence
that signed this instrument, on oath
stated that, (he/she) was authorized to execute the
instrument and acknowledged it as the (title)
of (name of party on behalf of whom instrument
was executed)- t6 be the free and voluntary act of such party for
the uses and purposes mentioned in this instrument.
DATED this — day of , 199_.
NOTARY PUBLIC
My commission expires:
WSS52079A/0006.040.034 -5-
WSS/klt 02/0S/90 von. 315 9 PacE 2.5 6 2
9605080287
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PAGE �2
t UNITED SERVICES AUTOMOBILE ASSOCIATION MAIL MACH -D
0 9800 Fredericksburg Road - San Antonio, Texas 78288
AMENDED DECLARATIONS PAGE - EFFECTIVE 05/30/97
Named Insured and Residence Premises Policy Number
DOLORES S DEAN
USAA 00045 80 74 94A
16315 75TH PLACE WEST
EDMONDS, SNOHOMISH, WA 98026-4913
POLICY PERIOD From: 05/01 /97 To: 05/01 /98
(12:01 AM, standard time at location of the residence premixes)
COVERAGES AND LIMITS OF LIABILITY
SECTION I A Dwelling
$800,000
C. Personal Property
$600,000
D. Loss of Use
UNLIMITED
SECTION II E Personal Liability - Each Occurrence
F. Medical Payments to Others - Each Person
---------------------------------------------------------------------
$1 , 000, 000
$5,000
Your premium has already been reduced by the following:
FIRE/BURGLARY CREDIT $439.67 CR
NEW HOME DISCOUNT $586.22 CR
BASIC
PREMIUM $2,207.03
OTHER COVERAGES AND ENDORSEMENTS
Form and Endorsements are printed on the following page. $1,073.20
DEDUCTIBLES (SECTION I ONLY)
We cover only that part of the loss over the deductible stated.
ALL PERILS $1,000
DEDUCTIBLE CREDIT $937.96
S IS
In Witness !Whereof, this policy is signed on 05/29/97
V. /
Robert T. Herres
General, USAF (Retired))
Attorney -in -Fact F�EFER TO YOUR POLICY FOR OTHER COVERAGES, LIMITS AND EXCLUSIONS.
ATTACH THIS DECLARATION TO PREVIOUS POLICY
HO-DI (04-931
32XIE
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101
m UNITED SERVICES AUTOMOBILE ASSOCIATION
L)SMAMENDED DECLARATIONS PAGE - EFFECTIVE 05/30/97
Policy Number Policy Term: 05/01 /97 05/01 /98
USAA 00045 80 74 94A Inception Expiration
ADDITIONAL INSUREDS
CITY OF EDMONDS
SPECIFICALLY LISTED BELOW ARE
THE DECLARATIONS AND PREMIUMS FOR
ENDORSEMENTS MADE A
PART OF THIS POLICY AT
THE TIME OF ISSUE. THE ENDORSEMENTS ARE
ATTACHED STATING
TERMS AND
CONDITIONS.
IN FORCE
QR9WA
(o4-93)
QUICK REFERENCE -PREFERRED PROTECTION
IN FORCE
HO-9RWA
(04-93)
PREFERRED PROTECTION PLAN
IN FORCE
HO-17
(04-94)
ADJUSTED BUILDING COST
ADD
HO-41
(10-96)
ADDITIONAL INSURED
IN FORCE
HO-216
(04-93)
FIRE/BURGLARY PROTECTION CREDIT
IN FORCE
HO-370
(o4-96)
EARTHQUAKE
$1,032.00
IN FORCE
HO-70
(04-93)
RESIDENCE RENTED TO OTHERS
$41.20
REASON (S) FOR CHANGE:
MISCELLANEOUS POLICY CHANGES
110-132 (04-93) 05/29/97
PAGE 3
32 X C:
1 01
ADDITIONAL_ INSURED
In consideration of the person or organization shown in this endorsement having met and complied with our
acceptability requirements, this endorsement forms a part of the policy.
The definition of insured in this policy includes the person or organization named in this endorsement with
respect to:
COVERAGE E - PERSONAL LIABILITY COVERAGE F - MEDICAL PAYMENTS TO OTHERS
BUT ONLY WITH RESPECT TO RESIDENCE PREMISES.
IF THIS POLICY IS CANCELED OR NOT RENEWED BY US, THE PERSON OR ORGANIZATION SHOWN IN THIS
ENDORSEMENT WILL BE NOTIFIED IN WRITING
This coverage does not apply to bodily injury to any employee arising out of or in the course of the
employee's employment by the person or organization named in this endorsement
The person or organization named in this endorsement is not responsible for the payment of any premiums.
Any premiums returned and any dividend we may declare will be paid to the named insured.
The named insured is authorized to act for the person or organization shown in this endorsement in all
matters pertaining to this insurance.
This endorsement is added at the request of the named insured. Coverage under this endorsement does not
grant membership or associate membership or grant or imply eligibility for membership or associate
membership.
Except as specifically modified in this endorsement, all provisions of the policy to which this endorsement is
attached also apply to this endorsement
Name and Address of Person or Organization: Interest CITY/MUNICIPALITY
CITY OF EDMONDS
250 5TH AVE N
EDMONDS WA 98020-3146
Location of Premises:
16315 75TH PLACE WEST
EDMONDS, WA
HO-41 (10-96)
Copyright, USAA 1996. All rights reserved.
32X L
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' .FROM '' FIRE DEPARTMENT ,„,'. ,DATE
"X ENGINEERING DIVISION r-_ -:DATE.-
PLANNING DIVISION DATE
OWNER DUA?J i PrS -RP S ADDRESS 163IS;-7SZR- Fe---
PERMIT A00 oL B# INSPECTED ON
A field inspection was conducted to determine compliance with approved plans. Final approval
denotes there are no objections to the granting of
Occupancy for the building Performance Bonds may be released
Landscaping is approved
Other inspected
PASSED FIRST INSPECTION - CONDITIONS NOTED
1.
FAILED INSPECTION - OUTSTANDING REQUIREMENTS - RECALL FOR
INSPECTION
1.
2.
3.
4.
OCCUPANCY OR FINAL APPROVAL DATE 6 S % BY A
RE -INSPECTED - APPROVED DATE BY
RE INSPECTED - FAILED DATE BY
1.
2.
32 X I
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APPLICANT/OWNER'S LIABILITY LANDSLIDE ACKNOWLEDGMENT
DECLARATION
a) That the accuracy of all permit submittal
information is warranted by the applicant/owner in a form which relieves the City and its
staff from any liability associated with reliance on such permit application submittals.
While an application of the applicant/owner and her/his design professionals (ECDC
19.05.030) and, b) That the applicant/owner understands and accepts the risk of
developing in an area with potential unstable soils and that they will advise, in writing, any
prospective purchasers of the site, or any prospective lessees of structures on the site, of
the slide potential of the area. (ECDC 19.05.040C)
Signature of applicant or applicant's representative
(Dolores Stimac Dean)
Subscribed and sworn to before me this q�h day of %bru 1996
Notary public in and for Kuala Lumpur, Malaysia
Residingat 102 Jalan Bangsar, 59200 Kuala Lumpur
REGEIVF-0
F E B 2 7 1996
p;:RM!'f i;QL'F111=F
32XIE
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PLICANT/OWNER'S LIABILITY LANDS1,101: AC:KNuw1.L'Ut1NIL'Nr 1JL'ULAKAVIUN
a) That the accuracy of all permit submittal information is
warrauted by the applicant/owner in a form which relieves the City and its staff from any
liability associated with reliance on such permit application submittals. While an application
nay reference the reports of prior public consultants to the City, all conclusions shall be'those
of the applicant/owner and her/his design professionals (ECDC 19.05.030) and, b) Tltat the
applicant owner understands and accepts the risk of developing ill an area with potential
unstable soils and that they will advise, in writing, any prospective purcinascrs of the site, or
any prospective lessees of structures on the site, of the slide potential of the area. (LCDC
19.05.040C) 1
r
- LkD
r ibnaturc of applicant or applicant's representative ; ..
Subscribed and sworn to before Mr -this rap day of 19_
O
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M1�. O • p".,ti o�
;� Notary .Public in and. for the State of Washington
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;7 ''PROJECT REVIEW CHECKLIST
PR�LEt� �V/CME"� .:Plll��l-is r PLAN CHECK#: S'
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PROJECT ADDRESS SIG �t� 7�_ ' L RECEIPT DATE-
s. e
Reviewed By:AZA
FIRE PLANNING ENGINEERING VPUBLIC WORKS
FILE:DATA123/PROJCKLS.SFN RECEIVED
NOV U 9 1995