21105 72ND AVE W.PDFiiiiiiii iiiiii
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21105 72ND AVE W
E RECEIVED
PERMIT EXPIRES
CITY OF EDMONDS
.CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF, BUSINESS
i'_1itV 0f E&OI-ILIS
MAJUNG ADDRESS
121
CITY ZIP TELEPHONE
allnn'L' --� 9�31020 425.771.0221
P.S..
V
V218 llldrd AvtF:. it'306
CITY ZIP
NAME
ADDRESS
6 ", 1 . � i. .1
13"vd.
CITY ZIP TELEPHONE
98233 360.75'7.7574
STATE LICENSE NUMBER EXPIRATION DATE /'el
1.N;Pf!111f_11'12'i Oij, 11 . 03.03
PRORERTY TAX ACCOYNT PARCEL N
0 NEW
0 RESIDENTIAL
0
PLUMBING / MECH
/OTW6 10:/6
ADDITION
E] OeMMERCIAL
o
COMPLIANCE OR
CHANGE OF USE
0 REMODEL
0 APARTMENT
0
SIGN
0 REPAIR
0 GRADING
CYDS
0
F
( -E
STRE
0 DEMOLISH
0 TANK
0
0
o. GARAGE
-1 RETAINING WALL
0
0
RENEWAL
CARPORT
ROCKERY
I(TYPE OF USE, BUSINES�SR �CTIVITY]l EXPLAI
NUMBER
OF
NUMBER OF
DWELLING
0_
CRITICAL
AREAS
STORIES
UNITS '0
NUMBER,
Aj
DESCRIBE WORK TO BE DONE
HEAT SOURCE I GLAZIN13 % 'i I LOT SLOPE %
PLAN CHECK NO; �,, �' I .- I VESTED DATE
USE
ZONE
jots
ADDRESS
PLAT NAME/SUBDIVISIQN NO.
PERMIT IT
NUMBER
LOT NO. UD NO.
UP FEE$
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
Zi;i�_
iiT Per uIled
Street Use Permit ReqW
EXISTING — PROPOSED
Inspection Required
Sidwalk Required
REQUIRED DEDICATION— Fr
Underground
Wiring required
METER SIZE
LINE SIZE
I
NO. OF FIXTURES
PRV REQUIRED
I
YES 0 NO E3
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
ENGINEERING
FIRE REVIEWED BY
REVIEWED/DATE
DATE
z
z
rL
VAR N C E OR CU
0
SHORELINE OR ADB#.,
INSPECTION
�rVARIANCE
— _
E 'D
040
S 13 NO
I PDOND
OSTED
A E
SEPA REVIEW
S E R V
PE
COMPLETE E
Cc MPL T E EXEMPT
SIGN AREA
ALLOWED PROPOSED
HEIG
ALLOWED PROPOSED
Y,
I
__f.1
:1 k—
EXP
LOT COVERAGE
REQUIRED SETBACKS (Fr.)
PROPOSED SETBACKS (Fr.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT UR SIDE REAR
PTz
PARKING
LOT AREA
PLANNING REVIEWED BY DATE/,
RE R IDED
a!, P OV
L
c_'(
I /N 4f ��,,vlt6 Am I
THIS PERMIT AUTHORIZES ONLY THE WORK NOTqD. THIS PERMIT COVERS WORK TO
t BE DONE ON PRIVATE PROPERITY ONLY. �ANY 9ONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, AIARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISPION.
PERMIT APPILICATION: 160 DAYS
AL PERMIT UMfP 1 YEAR - PROVIDED WORK IS OTARTE6 WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR M9RE INFORMATION
'APPLICAK ON BEHALF OF HIS OR HER SPOUSEI HEIRS, ASSIGNS AND SOCCESORS
IN INTEREST, AGREES TO INDEMNIFX DEFEND 1.
�ND HOLD HARMLESS THE CITY OF
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURF, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT ISSUAN9E OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY; WAIVE OR REDUCE ANY REOPIREMENT OF ANY CITY ORDINANCE
0 ,--'kOR LIMIT IN ANY WAY THE CITYS ABIL17Y TO ENI�PRCE ANY ORDINANCE PROVISION!
I z I
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS A�PUCATION; THAT THE INFORMATION
GIVEN IS CORRECP AND THAT I AM THE OWNER, 0�1 THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC.
TION; AND IN DOING THE WORK AUTHORIZED THERE , BY, NO PERSON WILL BE EMPLOYED
IN VIOLAT ON OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
IC
WORKMEN'S. COMPENSATION INSURANCE AND RCW,48.27.
SIGNATURE (0 NER OC.,%GE
NJrp I DATE S19NED
a
A17ENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
10/01
CHECKED BY ITYPE OF CONSTRUCTION OCCUPANT
4kzwt V_/V TV GROUP
SPECIAL INSPECTOR JAREA OCCUPANT
REQUIRED [] YES 1 �?�2. LOAD
REMARKS . 2
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D
VAWATION $ I ( )( ) ( ')
Description
FEE
Description
FEE
Plan Check
Building
Plumbing
Mechanical
Grading
Recording Fee
Engr. Review
City Surcharge
Engr. Inspection
State Surcharge
Traffic Mitigation
Plan Chk Deposit
Fire Review
Receipt #
Fire Inspection
Total Amount Due
Landscapelnsp.
Receipt #
APPLICATION APPROVAL
CALL This application Is not a permit until signed by the
Building Official or his/her Deputy: and Fees are paid, and
FOR INSPECTION receipt Is acknovAedged In space provided.
OFFICIALS 19NAT 11 DATE
1495)
t;v
771-0220
R BY D&E
EXT 1333 61
17
7
&,"
771-0221 _-7)
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FAX PINK - OWNER - GOLD - ASSESSOR
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