HomeMy WebLinkAbout1010 E 4th St_BLD6259_2025
OPERATING PERMIT APPLICATION
Community & Economic Development
City of Arlington • 18204 59th Ave NE • Arlington, WA 98223 • Phone (360) 403-3551
Part I
Property Address for which Operating Permit is requested:
Parcel ID No.: Current Occupancy
Project Description:
Applicant Name: Home No.:
Email Address: Cell No.:
Mailing Address: City: State: Zip:
Contact Person: Phone No.:
Part II
Type of Operating Permit
An Operating Permit is required to conduct any activity or to use any class of building listed below. Please indicate
the type(s) of Operating Permit(s) requested by checking each applicable box. (If you require assistance, or would
like more information, contact the City of Arlington Building Department at 360-403-3551.)
Manufacturing, storing or handling hazardous materials in quantities exceeding those listed in the Fire Code
(see Appendix A.) Identify the materials and quantities and describe the manner in which the materials will be
manufactured, stored or handled (attach additional sheets if necessary): _______________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Conducting a hazardous process or activity, including, but not limited to, any commercial or industrial
operation which produces combustible dust as a byproduct, fruit and crop ripening, waste handling, spray
operations, and high-piled storage (see Appendix B.) Describe the process(es) or activity(ies) to be conducted
(attach additional sheets if necessary): _____________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
REV032021 Page 1 of 3
Use of pyrotechnic devices in assembly occupancies (see Appendix C.) Describe the devices to be used and type
of event (attach additional sheets if necessary): ____________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Aboveground Storage Tank (AST) (see Appendix D)
Removal Decommissioning Temporary tank closure Changes in service
Permanent tank closure
Brief description: ____________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Underground Storage Tank (UST) (see Appendix D)
Removal Decommissioning Temporary tank closure Changes in service
Permanent tank closure
Brief description: ___________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Temporary Membrane Structures, including tents and canopies (see Appendix E.) Brief description of structure
and use: _______________________________________________________________________________________________________________
___________________________________________________________________________________
Special Event Operating Permit - An Operating Permit is required for any special event that takes place within
an occupied building, or an outdoor mass gathering, which is outside the scope of the permitted use (see Appendix
F.) Brief description of type of gathering proposed: _______________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Mobile Vendor - (see Appendix G.) Brief description of vehicle and use: ____________________________________
___________________________________________________________________________________
Part III
Premises/Building Information
1. Date of last inspection of Premises: ______________________
2. Has a Certificate of Occupancy been issued for the premises? Yes No
Type: Permanent Temporary Date of Issuance: _____________________________________________________
REV032021 Page 2 of 3
3. Are there currently any open Building Permits associated with the premises? Yes No
If yes, please describe (attach additional sheets if necessary): _______________________________________________
_____________________________________________________________________________________________________________________
________________________________________________________________________________
4. Additional Comments: ____________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
SIGNATURE OF APPLICANT
I herby certify that the foregoing information (and all information in attached sheets, if any) is true and complete.
__________________________________________________________________________________________________________________________
Signature of Applicant or Authorized Representatives Signature Date
__________________________________________________________________________________________________________________________
Name and Title (if applicable) of person signing Application (Please print)
Part IV
To be completed by the City of Arlington Building Department
Inspection Required: Yes No
Inspections Performed: Yes No Date of Inspection:
Tests or Reports required verifying compliance? Yes No
If YES, have Tests or Reports been received? Yes No
OPERATING PERMIT APPROVED
Operating Permit Issued by:
Date Operating Permit Issued: Date Operating Permit Expires:
Type/Description of Operating Permit:
Conditions of Operating Permit (list conditions here AND in the space provided in the Operating Permit:
Additional Comments: (Attach additional pages if needed)
REV032021 Page 3 of 3
!"# $%&'()*+,
-."/# 0123,4$(+,52,3'6778
-."/-99:: ;+< =
-."/>?>@>A B2,3CDC E
? /" F+&,G2H2(
I / J EJEEK
L. %+,3'%3M*'('&52H2(N15'$6M%+5
@" OP Q R2%+55$**$+,',)(25+42(2*$)2,3$'60,)2(1(+0,)&2'3$,1+$63',S
T.U / M
@VUW
#UX O@ :
? /:U" / 6
Y""U/"Z U J[2*$)2,3$'6
\? 9
\::U9 K
L]: K
W
@U: 8G7
-::^/9 52(2*$'7'_6$*
'(%26` ))(2**721'6R2*%($a3$+,_,2( '52 _,2(&+,2 b+,$,1
8cRd d 7
E E cd FGdRe fG 7g
dc d R 8
? /" :
8+,3('%3+(($5'(H8+,3'%3&+,2))(2**8+,3('%3+( Ha27$%2,*2 7$%2,*2`
0123,4$(+,52,3'6 F+&,G2H2(e 3&42 8+,*3(0%3$+,
J EJEEK h K =ib
778 d'('&G2H2( `= 8+,3('%3
\/:" /:
R'32 ,*a2%3$+, Ha2R2*%($a3$+,d%&2)062)R'328+5a6232)R'32 ,*a2%3+(d3'30*
=
!"#$%#&'
( )*+,-( -
. , )*+/
.-- * +
0101 234).,567/5 - 8 9 9 :;;<=5>(567
?##'
@( -
6 .
3 0, ; AB
5 - AB
/ * A
CDE FGHIJHH
KEE LM#NO#EE#P'
( > ( -
0101 QRSTUVWXYZ[\][^_`aa\[bcd[U^
ef#!E'
( 3 <( -
3 ,-.- <.
g<3 h
0 01 A
1 Bi
0 01 / 1 Bi A
jkE'E !N%!lm !L# FHJHH
nDE#'
( 6 <h
0 01
!"
!"
#
$%&'()'
*
+,
)'
-% ,./012 345261073829:082;<2=782<>6?=0@@
$(- 5587A2;B01CD73;010734
E-- #.',FG HI !"
J.*
K(*
L,( -M
, J.N, ,.
>862@O*PP DQ I/!R S /IT/ Q
DQ I/!R S /IT/ Q Q/
Q/ H !" !UV P W
X7303Y*/ !"H Z S H[
/ I !D H71*F@76?*