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22937 HIGHWAY 99
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I -) IPERMIT
EXPIRES
CITY OF EDMONDS
USN
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PERMIT ,
NUMBERM2— "_ 7-
CONSTRUCTION PERMIT APPLICATION
CATION
J
JOB
0
A
ADDRESS
OWNER NAME/NAME OF BUSINESS
FLAT
PLAT NAMEISUBDIVISION NO.
OT NO.0
LID NO.
MAILING ADDRESS
LID FEE S
PUBLIC X3HT OF WAY PER OFFICIAL
T
STREET MAP
=
ZIP
TELEPHONE
EXISTING — PROPOSED
—
S_ U.. e
Wp� Req� 13
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REQUIRED DEDICATION—
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NAME
METE
METER SIZE
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FIXTURES
REQUIRED
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FPRV
Y S 0 NO 0
ADDRESS
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WNER)CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
-ITY
NAME
ADDRESS
CITY
STATE LICENSE NUMBER
ZIP I TELEPHONE
[j NEW
0 RESIDENTIAL
[] PLUMBING I MECH
C] ADDITION
[] COMMERCIAL
I
gd�n�
0 REMODEL
0 APARTMENT
0 SIGN
REPAIR
GRADING CYDS
[:, FENCE
I — X
0 DEMOLISH
0 TANK
0 OTHER
GARAGE
CARPORT
Ej RETAINING WALL
ROCKERY
RENEWAL
UWE
NUMBER
L&MBER OF
CR ITIC
_FA
OF
DWELLING
It EA S
STORIES
UNITS
N UMBER
DESCRIBE WORK TO
BE OONO
FIRE REVIEW D BY
FIR' R E V'
DATE
-1-02-
By
VARIANCE OR CU
SHORELINE OR ADS#
INSRPEEaJON
I PBOND
OSTED
13yrSWN0 I
A
SEPA REVIEW
S EP
SIG14 AREA
EIGHT
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
EXP7----�-
[EMARjr
LOT COVERAGE
REQUIRED SETBACKS (Fr.)
PROPOSED SETBACK$ (Fr.)
ALLOWED PROPOSED
FROM SIDE REAR
FRONT URSIDE REAR
1W 61'14At-,F_ f
R10
PAR. No
LOT AREA
PLANNING REVIEWED ?Y DATE
O'D 'PROVIDED
CHECKED BY
I TYP9ffNMON
j2y�-
CUPANT
OCROUP /n
SPECIAL INSPECTOR
REQUIRED [:I YES
[AREA
OCCUPANT
LOAD
REMARKS ZO
PROGRESS INSPECTIONS PER UBC IGOIFINAL INSPECTION REG-D 9
VALLIATION
Descripitlon
FEE
D.Sciripti..
FEE
g::L� 1 rrLfj��)eIq
Plan Check
qc->
EAT uhE LOT SLOPE % '
Building
PLAN CHECK NOnl.LIVI VESTED DATE
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DOME ON PRIVATE PROPERTY OHL% ANY CONSTRUCTION ON THE PUBLIC
DOMAIN SIDEWALKS.
Grading
Recording Fee
(CURBS, DRIVEWAYS 1*UEES, I .) WILL REQUIRE
SEPARATEPERM;SSIOHL
rc
PERMITAPPLCATION: ISO DAYS
Engr. Review
City Surcharge
PERMIT UMM I YEAR - PROVIDED WORK 15 STARTED WITHIN ISO DAYS
Engr. Inspection
State Surcharge
SEE RACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT. ON BEHALF OF PUS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
Traffic Mitigation
Plan Chk Deposit
IN INTEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
Fire Review
Receipt III
ALL CLAIMS FOR DAMAGES OF WHATEVER MATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF THIS PERMIT SMALL DMOT BE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY OR 'NANCE
Fire Inspection
Total Am ount Due
0 NOR LIMIT IN ANY WAY THE CITY% ABILITY TO ENFORCE ANY ORDINANCE PROVISION...
Landscapelnsp.
Receipt #
I HERESY ACKNOWLEDGE THAT � HAVE READ TH S APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT, AND THAT AM THE OWNEIR. OR THE DULY AUTHORIZED AGENT OF
APPLICATION APPROVAL
E
THE OWNER. I AGRE TO COMPIY WITH CITY AND STATE LAWS REGULATING CONSTRUC.
CALL
ThIs application Is = a Feted until siWmd by the
n ON: AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON BE EMPLOYED
WILL
BUIlding OffiCial m hisftw Deptay; md Feee we paid. Iud
IN I?N OF THE LABOR CODE 01 THE STATE OF WASHINGTON RELATING To
FOR INSPECTION
receipi is �no�odgee In spece P1 .0.
WOW COM!ENSA.TjftjfUR&NCE AND RCW 18.27.
SIG , tow FR 0 E —E SIGNED
(4,25)
OFFIC IGN U IFT02,
771-0220
"ftENTION
RELEASED BY'
A
EXT 1333
-2
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CEFITIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
ortiriNAL - FILE/ YELLOW /NSPE&OR
PINK OWN6-e GOLD ASSESSOR
10/01
- -
PERMIT EXPIRES
USE PERMIT
CITY OF EDMONDS ZONE NUMBER No
CONSTRUCTION PERMIT APPLICATION JOB
ADDRESS
OWNER NAMENAiLE OF BUSINESS
PLAT NAME/SUBDIVISION NO. COT NO. LID NO�
MAILING ADDRESS LID FEE $
TESCP
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP par�= .
;1?a RW
strestusepannk"
CITY ZIP TELEPHONE EXISTING PROPOSED hupecdo Required
SMidewwaalk,
REOU 0 4DICATION— FT Undwgr&jW
j.
NAME
M SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YESO NO 13
ADDRESS REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
CITY ZIP TELEPHONE
NAME_
ENGINEERING REVIEWED/DATE
ADDRESS
qua ou FIRE REVIEWED BY DATE W
CITY zip� TELEPHO14E cc
rL
VARIANCE OR CU SH INSPECTION IPSOND
STATE LICENSE NUMBER EXPIRATION DATE I CHECKED BY REO-D OSTED
VYES. [3 NO
SERA REVIEW SIGN AREA . HEIGHT
I.A4, AM I
P77ACCOUNT PARCEL NO. # . . . .
0 )o 0.2 r COMPLETE EXEMPT ALLOWED PROPOSED ALLOWEf PROPOSED
EXP IX 14 119,4** 14 110118"
LOT COVERAGE REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (FT.)
�NW 11 RESIDENTIAL 0 PLUMBING I MECH �ALLOWED PRPP�PSED, FRONT SIDE REAR FRONT* L/RSIDE REAR
k MP
ADDAN CO
C2;rCE R
OMMIERCIAL oi� , W-A /'� I /A ff-X-15 N C, FX1S11N6;,
'f Lo� iAkk P :VI
OAAING k EDgf
0 RE APARTMENT SIGN REO'D I PROVIDED1 �IDATE
[j REPAIR GRADI . N . G CYDS Lf FENCE W
X FT) REMARKS
.[3'DEMOUSH TANK -OTHER
[i GARAGE o RETAINING wALL
CARPORT ROCKERY RENEWAL
OWE OF USE, BUSINESS OR ACTIOM EXPLAIN:
CHECKED By TYPE 0 USTRX ON OCCUPANW
(3 I -a" GROUK.D
0 A
NUMBER NUMBER OF CRITICAL
OF 6 DWEWNG AREAS SPECIAL INSPECTOR JAREA' OCCUPANT.
2ME UNITS �j NUMBER REQUIRED LOAD
DESCRIBE WORK TO 13E DON.
REMARKS.
PROGRESS INSPE�TIONS PERUBC 108/FINAL INSPECTION REGrD
ra-r oh
elvj 5 h NhIL'I k#131
C-11-io An < oi<-) 6o5h1c w',re
r
ne'kj
IN ,A,-/'% h r7c ?/I
HEAT SOURCE GLAZING % .LOT SLOPE %
PLAN CHECK NO:
VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED....THIS PERmITCOVERB WORKTO
BE DONE ON PRIVATE PROPEMY ONLX ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS,.1111 ARQUEES,' ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180 DAYS
PERmrr.uMM I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFOMUTION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESOkS
IN INTEREST, AGREES TO INDEMPPK DEFEND AND HOLD HARMLESS THE C17Y OF
EDMONDS, WASHINGTON, ITS OI§FICIALS. EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OPWRATEVER. NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PEFimrr. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFX WAIVE OR REDUCE AW. REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITVS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPUCATION; THAT THE INFORMATION
GIVEN IS CORRECT� AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT df
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE, LAWS REGULAT1N0,CoNsTRUC.
TION; ANJ)IN D IN HE RIZED THEREBY, NO PERSON WILi-SE EMPLOYED
0 GT W I
VIOIATA N OF THE LAB& �DEIDF THE STATE OF WASHINGTON RELATING TO
1
67
PEN;4 SU 9"D� RCW 18.27.
VE�S C r
VAWATION $
011111-9heft
Building
Plumbing
Mechan ical
Grading
Engr. Review
Engr. Inspection
Traffic Mitigation
Fire Review
Fire Inspection
FEE
2-
FEE
Recording Fee
City Surcharge
State Surcharge
Chk Deposit
tPlan
Receipt #
T Toi
otal Amount Due
ndscape Insp.... Receipt #
APPLICATION APPROVAL
CALL. This application Is not a permit until signed by the
Building Official or his/her Deputy: and Fees'are pald. end
FOR INSPECTION A receipt Is ack-novAedged In space provided..
OFF*I.S SIG.NATIAE A E
IA251
7-7 26 .1 DATE
ATTENTION,` E)ff<13U
b-L
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTORE UNTIL �7
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A, CERTIFI-
CY HAS BEEN GRANTED. UBC SECtION 109 PINK - OWNER - GOLD - ASSESSOR
CATE OF OCCUPAN ORIGINAL - FILE - YELLOW - INSPECTOR
10/01
r) ' ( cll�
2fA* IL k � 07r, "