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CITY OF EDMONDS �
CONSTRUCTION PERMIT APPLICATION
OWNERNAMENAME OF B SINESS
11 MA
.ILINGADDRESS
1 701 4,V4 NA,l'J
I CITY ZIP I TGLEPmuNE
[P�ERMIT EX�PIRES
PERMIT 7 3
NUMBER
iTVAPTN
JOB
ADDRESS
SU
PLAT NAMEISUBI)iVISION NO,
LOT NO.
LIU NU.
LID FES $
P �. '
RIGHT OF WAY PER OFFICIAL STREET MAP
d 0
1— wl 0
EXISTING — PROPOSED—
P.d Q4 0
REQUIRED DEDICATION— FT
PAN REOUIRED
YES C3 No 0
ADDRESS
OWNEAWNTRACTOR RESPONSIBLE FOR EROSION WIN I z
CITY
"",,'kIP ITELEPHONE
NAME
A/ A-t 10 A/A L 11 Ofil; C
NGINEERING
HhV'tw,wDATE
_1 ADDRESS
13 :1) 4,
DATE
CITY ZIP
0
rur WA.
TELEPHONE
42 _5__'7W
FIRE REVIEWEDBY
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INSPEC TION BONO
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VARIANCE OR CU
SHORELINE OR AUB#
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POSTED
STATELICENS NUMBER
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PROPER
0,7
COMPLET EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
3 DZIO q -4-
EXP
-
LOT COVERAGE
REQUIRED SETBACKS( I
PROPOSEDS SACKS (FT.)
NEW
0 PLUMJINGIMECHI
ALLOWED PROPOSED
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FRONT LIASIDE REAR
ADDITION
o COMPLIANCEOR
CHANGE OF USE
PARKING
LOTAREA
PLANNING REVIEWED
By DATE
REMODEL
0 A
FENCE
0 REPAIR o GRADING CYOS 0 _ X FT)
HEMP-
0 0 o OTHER
q DEMOLISH 0 TANK
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CHECKED BY TYPE C
RNSTRUCTION D 0
OCCUPANT
FOUP
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HT ;ER U
A
AREAS
SPECIAL INSPECTOR AREA
OCCUPANT
LOAD
I
D I
DWELL NO
OF \ I NITS
NUMBER
REOUIRED 0 YES
STORIES
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS PER UBC 1081FINAL INSPECTION REQTI
. . ... ........
145 U2 h I'L
VALUATION
FEE
PLAN CHECK FEE
HEATSOURCE
LOT SLOPE I
B LOING
PLAN CHECK NO:
... IEDOATE
PLUMBING
MECHANICAL
THIS PER AU Rlzfs ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
SEE MIT . THO V Y CONSTRUCTION ON THE PUBLIC
' ONE NPA ATE PROPERTY ONLYAAN
GRADINGIFILL
AAGU )W HIS
(C , SIDEWALKS DFAVEW Y. EES,ETC. ILLREOUt
DOM AIN URSIS _
E�AAAT.PEAMSIS'O..
L
G:P;��S RCHARGE
PE RMIT APPLICATION: 180 DAYS
PROVIDED WORK IS STARTED WIT
PERMIT LIMIt I YEAR SIN 180 DAYS
ENG.REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF F HIS OR HER SPOUSE. HEIRS. ASSIGNS SU CGS AS
N THE ITY F
'L C"Ti.OA DEFEND AND HOLD A L
;N
ENG, INSPECTION PEE
LANDSCAPING
GGS T
I NT...ST AGREES T :NDEMNIFY,
F
TS OFFICIALB EMPLOYEES, AND e R ANY AND
INSPECTION FEE
JR. -IN-- ---- 11
PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
RECEIP I I
'4
OF ANY CITY ORDINANCE
ROMANCE PROVISION.'
REC
14
TOTAL AMOUNT DUE
THAT EINFORMAIION
THE
APPLICATION APPROVAL
AUTHOR ZED AGENT OF
REGULATING CONSTRUC.
CALL
Thi"p"'cat'"' "'. PiI V""i g,,d by th,
dl Ott
INWILLBEE LOYED
RELAMIPING TO
FOR INSPECTION
8"1 111-111pil'. .�kl�dg.d M p— 01.1d.d.
HINGTON
DATE
DATE S
(425)
�A
0 1 LS SIGNATURE
_/ 7_00
Sj��NAT GE C WNER ENT
WEASE
771-0220
D n
EXT 333
J6
AFFTION
UNTIL
UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
771-0221
YELLOW - INSPECTOR
IT IS
INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL - FILE
GOLD - ASSESSOR
A FINAL
HAS BEEN GRANTED. UBC SECTION 109
FAX
PINK - OWNER
CATE OF OCCUPANCY
wv� as RECEIVED
Fp
ERMIT �xp IRES
PERMIT
CITY OF EDMONDS
NUMBER
CONSTRUCTION PERMIT APPLICATION
JOB ITEMPTa
ADDRESS
cl
q
OWNERNAME AMEOFBUS EBB
14. V Cl
PLAT NAMEISUBDIVISION NO.
LOT NO. Ij
LI NO.
LID FEE S
MAILING ADDRESSIR,
�J& .,I J, 03
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
;UZZI-11 0
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0
CIT- —ZIP
EXISTING PROPOSED�
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JTELEPHO�E
�.�F T ':_J� 043
- ItT74
4LL� 14
REQUIRED DE [ON— FT —
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ME ER SIZE
LINE SIZE
NO. OF FIXTURES
PRY REQUIRED
NAME
Yes 0 No 0
ADDRESS
REMARKS
0 NTRaCTOR RESPONSIBLE FOR EROSION CONTROUU111 a
WNER/CO Z
CITY p TELEPHONE
NAME
TA) "A)47ioA1AL .171W)
ENGINEERING III E
ADDRESS
13 ++4 #,Fl
FIRE RE��Jjjj WIM I SON- DATE
CITY ZIP
TELEPHONE
q24-- ho 17
OR ADBU
INSPECTION
z
STATE LICENSE NUMBER EXPIRAItUl jl"o�
ViTi�R5 c c, I
CHECKEDBY'
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VARIANCE OR Cu
SHORELINE
lacy 00
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OST�.
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HEIGHT
PROPERTYTAX A C UNTPARCELNO.
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COMPLETE E;..PT
EXP
p
ALLOWT. OSED
45
ALLOWED I
14 P[4�El
:jj
LOTCOVEAAGE
REQUIRED SETBACKS (�.)
FRONT SIDE REAR
PROPOSED SETBACKS JFTI
FRONT URS30E REAR
E--.Ew
0 P'Um-1-nfNAFr.H
ALLOWED !PROPOSED
0 m
c
[3 AUDITIO�
o COMPLIANCEOP
CHANGE OF USE
REVIEWED
BY DATE
m
0 REMODEL
PARKING
R �D PRQ'IDEO
LOTAREA
PLANNING
o
rRADING CY.S n FENCE
0 REPAIR X FT�
U
REMARKS
m
0 DEMOLISH rl TANK C] OTHER
0
G ETAI
-AlA.1 NW. WALL f-I
c 2
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0 E .A FORT
C
IN ACT
(TYPE OF USE, CTIVITY� EXPLAIN:
CHECKEDBY TYPEO
O�STRU TION
Aly\
COURANT
C D OCCUPANT
GROUP
ROUP_74
'IfC.URANT
0 _n
.E. ME
NUMBER NYMBER OF EAS
AR
SPECI L NSPECTOR AREA#
OWEL ING
OF U IT, L
UNITS
U R_
N MBE
REOU RE YES
LOAD
m m
'TTi-SCRISE
STORIES
WORK TO BE DONE
RIMA
a
0
ORIKISESS INSPECTION ER UBC 1081FINAL INSPEC`rJo'N RECIG
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VALUATION FEE z
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PLANCHECKFEE
ai .'
0 U3
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LOT SLOPE %
BUILDING
PLAN CHECK NU:
ED DATE
PLUMBING
MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
GRADINGFiLL
DOMAIN (CURBS. SIDEWALKS. DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
zi SEPARATE PERMISSION.
L
RCHARGE
2 PE MITAPPLICATION: 180DAYS
R
K I
PERMIT LIMIT.. I YEAR � PROVIDED WOR S STARTED WITHIN 180 DAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
m -APPLICANT, ON BEHALF Or His OR HER SPOUSE, HEIRS, ASSIGN. AND SUCCESORS
ENG. INSPECTION FEE
IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY F
LANDSCAPING
M EDMONDS. WASHINGTON. ITS OFFICIALS. EMPLOYEES, AND AGENTS FRPM ANY A ,
OF WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY
INSPECTIONFEE
RECEIPT
14
ALL CLAIMS FOR DAMAGES
FROM, THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT S�ALL NOT E
PLAN CHECK DEPOSIT
L
D EMED TO -MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 'E Y WAY THE CITY'S ABILITY TO ENFORCE ANY.RD.NAN
08 LIMIT IN AN
RECEIPT
TOTAL AMOUNT DUE
IHEREB ACKNOWLEDGE THAT$ HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT, AND THAT I AM THE OWNER OR THE DULY AUTHORIZED AGENT Or
y
This leslicIal 11 nOt 8 P-i"'d "'t""" ad
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC,
CALL
B,lldclo Officiat a, h,sal., Deputy: ad Fees ae paid, ni,d
TiON; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
RELATING TO
FOR INSPECTION
irl is .�kwlad,.d P.. P-ld-d
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON
DATE
WORKMEN'S COMPENSATION INSURANCE AN RCW 18,27
DATE lIGwD
(42'rs)
OFF S SIGNATURE
771-0220
RELEASED DATE
EXT 333
96 3&7_1T
AtTEgTION
UNLAWFULTO USE OR OCCUPY ABUILDING OR STRUCTURE UNTIL
771-0221
IT IS
FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL - FILE YELLOW � INSPECTOR
A
CATE OF OCCUPANCY HAS BEEN GRANTED, UBC SECTION 109
FAX I"
PINK . OWNER GOLD . ASSESSOR