BLD20160121v�y of E MD�N
CITY OF EDMONDS
FINAL121STH AVENUENORTH - EDMONDS, WA 98020
C. 189 o PHONE: (425) 771-0220 - FAX: (425) 771-0221
STATUS: ISSUED 07/25/2016 , Permit #: BLD20160121
Expiration Date: 01/25/2017 j v - Project Address: -24025 74THAVE W, EDMONDS
Parcel No: 00488800701000
P&*?'EATV OWNER APPLICANT CONTRACTOR
FENG LIN T ED CLIFT ON OW NER EXEMP T ION
4534 165TH AVE SE 107 S MAIN ST STE 6201
BELLEVUE, WA 98006 COOPVILLE, WA 98279
(206)778-8714 (360)969-2363
LICENSE 4: EXP:
DEMO SFR
PSCAA #201603391
VALUATION: $0.00
PERMIT TYPE: Residential
PERMIT GROUP: 23 - Demolition
GRADING: N CYDS: 0
TYPE OF CONSTRUCTION:
RETAINING WALL ROCKERY:
OCCUPANT GROUP:
OCCUPANT LOAD:
FENCE: ( 0 X 0 FT.)
CODE: 2012
OTHER: ------- OTHER DESC:
ZONE:
NUMBER OF STORIES: 0
VESTED DATE:
NUMBER OF DWELLING UNITS: 0
ILOT 4:
BASEMENT: 0 1 ST FLOOR: 0 2ND FLOOR: 0
BASEMENT: 0 I ST FLOOR: 0 2ND FLOOR: 0
3RD FLOOR: 0 GARAGE: 0 DECK: 0 OTHER: 0
13RD FLOOR: 0 GARAGE: 0 DECK: 0 OTHER: 0
BEDROOMS:0 BATHROOMS:O
BEDROOMS:0 BATHROOMS:0
FRONTi •CK SIDESEI'BACK REARSETBACK
REQUIRED: PROPOSED: REQUIRED: PROPOSED: REQUIRED: PROPOSED:
HEIGHT ALLOWED:O PROPOSED REQUIRED: PROPOSED:
SETBACK NOTES:
I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUCTION 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
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27.
THIS APP�ICATIM I T A PERMIT UNTIL SIGNED BY THE BUILDING OFFICIAL OR HIS/HER DEPUTY AND ALL FEES ARE PAID.
Print Name Date
Date
v ATTENTION
ITIS UNLAWFUL 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. UBC] 09/ IBC110/ IRCI 10.
•
ONLINE APPLICANT = ASSESSOR 10OTHER i/ls
A
STATUS: ISSUED
BLD20160121
• *Pre -inspection required.
• *Street to be cleaned of debris.
• *Side sewer must be capped at property line.
• *Water Service must be disconnected from Water meter and or hose bib with AVB installed.
• *Dump at approved dump site only.
• *See demolition inspection checklist on back of job card for inspection requirements.
• Final approval on a project or final occupancy approval must be granted by the Building Official prior to use or occupancy of
the building or structure. Check the job card for all required City inspections including final 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 forwhich avariance 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.
• 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 7:00am to 6:00pm on weekdays and 10:00am and 6:00pm on Saturdays, excluding
Sundays and Federal Holidays. At all othertimes 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 of his or her 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 from the issuance for this permit. Issuance of this 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.
• Call for locates of underground utilities prior to any excavation.
• Maintain erosion & sedimentation control per city standards.
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 19.00.005(A)(6)
BUILDING (425) 771-0220 EXT. 1333 1 ENGINEERING (425) 771-0220 EXT. 1326 1 FIRE (425) 775-7720
PUBLIC WORKS 425 771-0235 1 PRETREATMENT 425 672-5755 1 RECYCLING 425 275-4801
When calling for an inspection please leave the following information: Permit Number, Job Site Address, Type of Inspection being
requested, Contact Name and Phone Number, Date Prefereed, andwbether you prefer morning or afternoon.
• E-Pre-Demolition Sewer Cap
• E-Pre-Demo Water Sery Discnct/AVB
• E-Pre-Demo Erosion Control
• &Engineering Final Demo
• B-Final Demolition
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5" Avenue N, Edmonds, WA 98020
Phone 425.771.0220 2 Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zi ):
2,1027 �{7'Gi- �✓ . £at r, r.Q/AAV qua 2 d
Parcel #:
G0y99800 7 0 o 0 0
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ® No ❑
Associated Permit #:
APPLICANT:
� L. , c4,Z tj
Phone:
360 969 Z7 6-7?
Fax:
ado- �82 2A
Address (Street, City, State, Zip):
E-Mail Address:
PR /PERTY OWNER: 4
�/ �
Phone-r
.G�
Fax:
Address (Street, City, Sta e, Zip):
4�23 0 .- .✓ e W
E- ail Address:
LENDING ENCY: 0
Phone: J 0
Vax:
Ad ss (Street, City, State, Zip):
E-Mail Address:
C7-940 ONTRACTOR: *
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
*Contractor must have a valid City of Edmonds business license prior to doing work
in the City. Contact the City Clerk's Office at 425.775.2525
WA State License #/Exp. Date:
City Business License #/Exp. Date:
PERMITAPPLICATION FOR:
PLUMBING I I MECHANICAL I I TANKI
I DEMOLITION
DETAIL THE SCOPE OF WORK: BEM o Sf Qj
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 property owner or duly authorized agent of the property owner to submit a permit application to the City of
Edmonds.
Print Name: C,L / r-7N Owner ❑ Agent/Other ® (specify):
Signature: Date:
FORM C L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
MEDICAL GAS, AIR, VACUUM
Type of Gas/Air/Vacuum System (new and relocated)
Total#
Oxygen
Nitrous Oxide
Medical Air
Carbon Dioxide
Helium
Medical — Surgical Vacuum
Other:
TOTAL OUTLETS
TANK #1
TANK #2
Method of Abandonment
Method of Abandonment
Fill in Place ❑ Fill Material
Fill in Place ❑
Fill Material
Removal ❑
Removal ❑
Number of Gallons:
Number of Gallons:
Critical Areas Determination: Study Required ❑
Conditional Waiver ❑
Waiver ❑
Type of structure to be demolished (e.g. house, shed, garage, etc.): Z -Wpnwi
S '"
Floor area of structure to be demolished:
E6 2—sq. ft.
Critical Areas Determination: Study Required ❑ Conditional Waiver ❑
Waiver ❑
PSCAA Case No.
AHERA Survey
done? (required) ❑
Additional comments:
FORM C L:\Building New Folder 2010\130NE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
EXEMPTION FROM CONTRACTOR
REGISTRATION VERIFICATION
FORM D
The undersigned property owner or authorized person as described below, has applied for a
building permit from the City of Edmonds and claims that he/she/it is exempt from providing
contractor registration in accordance with the provisions of RCW 18.27. The property owner or
authorized person, by their signature below, hereby verifies to the.City of Edmonds that:
❑ Value of work under $500.00. The aggregate contract price of labor and materials and all
other items required for the project is less than $500.00 and.is not part of a larger operation
to be undertaken on the property. This exemption does not apply to a person who advertises
or puts out any sign or card or other device which might indicate to the public that lie/she is
a contractor, or that he/she is qualified to engage in the business of contractor. RCW
18.27.09Q(9).
❑ Owner who contracts for a project. A property owner contracting with registered
contractors for the project, and who him/herself is not performing any activity of a
contractor for the purpose of leasing or selling improved property that he/she has owned for
less than twelve months. RCW 18.27.090(11).
Work performed personally on own.property. Anyone personally working on property
he/she owns, or at which he/she resides, as long as the property owner, or resident, does not
perform any activity of a contractor on his/her property for the purpose of selling,
demolishing, or leasing the property. RCW 18.27.090(12).
❑ Use of own employees. Property. owner using him/herself or his/her own employees to
perform maintenance, repair, and. alteration work in or upon his/her own property. RCW
18.27.090(13).
❑ Licensed Architect, engineer, electrician or plumber. All work performed under this
permit will be performed by an architect, civil or professional engineer, certified electrician
or certified plumber operating within the scope of his/her certification. RCW 18.72.090(14).
❑ Other. Specify which provision of RCW 18.27.090 applies:
THE UNDERSIGNED PROPERTY OWNER OR AUTHORIZED PERSON HEREBY VERIFIES
THAT ALL INFORMATION PROVIDED ON THIS FORM IS TRUE AND ACCURATE TO THE
BEST OF HIS OR HER KNOWLEDGE AND ACKNOWLEDGES THAT IF ANY OF THE
INFORMATION PROVIDED ON THIS FORM IS FALSE HE OR SHE UNDERSTANDS THAT THE
BUILDING PERMIT WILL BE IMMEDIATELY REVOKED AND ALL FEES PAID FORFEITED.
DATED this 0 day of IAA201
PROPERTY OWNER/AUTHORIZED
PERSON,
�w
Signature
'6 �_ L—Al
/
Print Name
!E�<— ,)
Signature
Print Name
LATEMP\BUILDING\HANDOUTS REVISED IN 2009\PREVIOUS HANDOUTS\FORMS\CONTRACTOR EXEMPTION FORM
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CITY COPY
JAN 2 9 2016
DEVELOPMENT SERVICES CTR.
CITY OF EDMONDS
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Project Name
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Client Name and AND2 5 74th Ave W.
Edmonds, WA 98026
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Project Name
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Client Name and A74f)2 5 74th Ave W.
Edmonds, WA 98026
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