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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNERNAMENAME FBUSINeSS
9 A.-3. c- -o
MAILINGADDRESS
CITY Z ITILEIHOME
ov evier-
NAME C0.3VI- IkA&AA"W-
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ADDRESS
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CITY Z TELEPHONE
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NAME
ADDRESS
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CITY ZIP `P ON
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STATE LICENSE NUMBER EXPIRATION DATE F Cq(
Ce:.V-" En-r- (!:) L% CmA ZJO-?- I ��)
C] NEW
C] RESIDENTIAL
[3 PLUMBING / MECH
ADDITION
C] COMMERCIAL
ci COMPLIANCE OR
CHANGE OF USE
C] REMODEL
APARTMENT
0 SIGN
REPAIR
0 GRADING CYDS
(FENCE X T)
0 DEMOLISH
0 TANK
OTr
oGARAGE
CARPORT
0 RETAINING WALL
—1—Y
0 RENEWAL
F/ I 1PERMITEXPIRES 'fl-q
U" PERMIT
ZONE NUMBER&�7/_611��,
JOB &W11&,$V.PT.
ADDRESS 9121A
FLAT NAMEISUBDIVISION NO. LOT NO L�D NO
L D FEE I
Ell
PUBLIC FfGHT OF WAY PER OFFICIAL STREET MAP
U.. I`—.
EXISTNG— PROPOSED —
REQUIRED DEDICATION— FT
PAV REQUIRED
ye. 13 NO 0
REMARKS
OWNERCONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
ENGINEERING
FIRE REVIEWED BY
DATE
VAR1ANCE OR CU
INSPECTION
,WELINEORAOII
I PBOND
OSTED
0,REQANO
ES
SEPA REVIEW
SIGN AREA
HEIGHT
Co
ALLOWED PROPOSED
ALLOWED PROPOSED
LOT COVERAGE
REQUIRED SETBACKS (FT.1
PROPOSED SETBACKS (7.)
ALLOWED PROPOSED
FRONT SLOE REAR
FRONT UPSIDE REA13
PARKING I
REDID i PROVIDED
LOT AREA
I 2N IEWED By OATS
(TYPE OF USE. BUSINESS OR ACTIVITY) EXPLAIN: CHECKED BY CONSTRUCTION OG PANT
I CODE GROUP
IN MBER NUMBEIRoFgStaof CRITICAL
DWELL NG R SPECIAL.SPECTOR JAREA OCCUPANT
OF UNITS A EAS C] LOAD
STORIES ?_ NUMBER REOUIREIN YES
DESCRIBE WORK TO BE DONE 40 JREMARKS
PER UBC 108fFINAL INSPECTION
I 4oqejvv, comg—r-itiLb-1. A"jgA!L)_j 4Ar-
VALUATION I FEE
PLAN CHECK FEE
HEAT SOURCE GLAZING I
LOT SLOPE
BUILDING
PLAN CHECK NO:
111STID DATE
ITO
PLUMBING
MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS �OAK
UC
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUB UC
GRADINGIFILL
G F.
I
OMAIN (CURB$, SIDEWALKS, DRIVEWAYS , MARQUEES. ETC.) WILL REQUIRE
W
SEPARATE PERMISSION.
S S TATE SURCHARGE z
46V
PERMIT APPLICATION: ISODAYS
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN ILK DAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
ON BEHALF OF H SIGNS AND SUCCESORS
NG. INSPECTION FEE
;APPLICANT.
N INTEREST, AGREES TO INDEMN15Y. DEFEND AND HOLD HARMLESS THE CITY OF
7A_N_DSCAPING
I E MONDS. WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AN.
D
INSPECTION FEE
ALLCLAIMS FoRDAMAGESOFWHATEVE11 NATLP E. ARISING DIRECTLY OR INOInCCTIY
RECEIPT
c FROM THE ISSUANCE OF THIS PERMIT ISS ANCE 01 THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
E
DEEMED To MODIFY, WAIVE OR REDUCE ANY . OU3REMENT OF ANY CITY ORDINANCE
PROVISION
N P LIMIT IN ANY WAY THE CITY S ABILITY TO ENFORCE ANYORDINANCE
o
TOTAL AMOUNT DUE
'5Z519
7/,,
ACKNOWLEDGE THAT I HAVE READ 111IS AFFLICATION. THAT THE INFORMATION
APPLICATION
APPROVAL
1 HEREBY
GIVEN IS CORRECT, AID THAT I A. THE OWNER. oA THE DULY AUTHORIZED AGENT OF
THEOVfNEA I AGREE TO COMPLY WITH CITY AND STATE LAWS RE rULATINGCONSTRUC-
CALL
Iy �d F
110N. AND IN DO NG THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
IT T
WASHINGTON RELATING 0
FOR INSPECTION
N VIOLAI ON OF THE LABOR CODE OF THE STATE OF
I I
WORENSCOMPENS��SURANCE AND RCW 18.27
SIGNATURE OAT'
SIGNATURE OWNER 04AGEN�
—
DATE SIGNED
(425)
AIIAII
mdwhjjo�, ��/
,
I If I _Lr�
FELEASE6 BY DATA
ATTENTION
EXT 1333
ITISUNL FULTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
AW
771-0221
A FINAL I N S PECTIC, N HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL FILE - YELLOW- INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
PINK -OWNER - GOLD ASSESSOR
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNSRNAMENAMEOFBUSINE S
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MAILING AD RESS
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ZIP ITILEPHONE
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ADDRESS ,
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CITY ZIP TELEPHONE
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NAME
ADDRESS
CITY ZIP, E�ON
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STATEUCINI NUMBER I
ceDr-1.4 ea:r- C-M -I-- I
[3 NEW 0 RESIDENTIAL r] PLUMBING/MECH
0 ADDITION
COMMERCIAL COMPLIANCE OR
CHANGE OF USE
I
0 REMODEL
APARTMENT SIGN
0 REPAIR
..A.M. CYGE [3 PENCE
I X
DEMOLISH
TANK
E] GARAGE
CARPORT
RETAINING WALL
ROCK�R
0 RENEWAL
IT,pE OF USE.-SU$INES§ OR ACTIVITY) EXPLAIN'
NUMBER
OF
NUM ER IF
DWELLING
AREA
STORIES
UNITS
N, E'R
i
DESCRIBE WORK TO BE DON . Ar'c'
rp�_*i 0 v r- 6_ 1� I � T?, c0T V4 I I M L>j
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USE
ZONE
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UMlER,<10/—e53
'5_
JOB
ADDRESS
LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL
STREET MAP
�p &X.,
P A-..
EXISTING — PROPOSED -
REQUIRED DEDICATION—
FT
METER SIZE
LINE SIll
NO, OF FIXTURES
RV REQUIRED
10
I
YEP NO 0.
REMARKS
MMERICONTRACTOR RESPONSIBLE
FOR EROSION CONTROUDRAINAGE
FIRE REVIEWED By DATE
VARIANCE OR CU
SHORELINE OR ADEIN
INSPE.jN
'ONO
RE
POSTED
N
c3YET7.
SERA REVIEW
SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALLO
ALLOWED PROPOSED
LOT COVERAGE
REOUIAED SETBACKS (Fr.)
PROPOSED SMACKS FT)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT UPSIDE I FIEAR
PARKING
LOT ARF7Pl_!.NtN.
REVIEWED BY DAT41U
RE.", I Pno�'G.o I
_
_
I — '(41 11 . � 1,
CHECXEDBY W
I Uu4A G�R�U'p7
FSPECIAL INSPECTOR JAREA PA , NT
REDEOU
R LOAD
IRED [3 YES OCC"
C - K E E
PLAN CHECK FEE
P
HEAT SOURCE
T S F E
LOTSLOPE%"
L
- D -
I I G
BUILDING
L
PLAN CHECK NO:
A T
ED DATE
E
'HE
PLUMBING
P L U B N
H A N I C A L
MECHANICAL
E C
"'D T C V E W on To
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
N T E P U
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PU BUG
G F L
' -L
GRADINGIFILL
RA N
G D '
T W L ED
DOMAIN (CURDS, SIDEWALKS, DRIVEWAYS. MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
t .
-T C A R E
STATE SURCHARGE
A T E S U
L
PERMIT APPLICATIO N: 160 DAYS
f
A K
PERMIT UMIT. I YEAR ' PROMED WORK It. STARTEDWITHIN 150DAYS
N o YE
V F E E s
E I W
E
ENG. REVIEW FEES
E . R
N
T
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
AN
T I..
P N 'E.
ENG. INSPECTION FEE
END IN S EC
I. S - SL.CE.. R
A N
A PPLICANT. ON BEHALFOF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESDRS
JSFD
IN 'NTERESt AGREES TO INDEMNIFY DEFEND AND HOLD HARMLESS THE CITY OF
-M LES S T. CITY o
ANY AND
no. ANY AN.
NN!
A N
G F'
LANDSCAPING
LAN
.. TS
EDMONDS. WASHINGTON, ITS OFFICIALS. EMPLOYEES. AND A DENTS FROM
ALLCILAIMS FOR DAMAGESQFWHATEVER NATURE, ARISING DIRECTLYOR INDIRECTLY
INSPECTION FEE
N E TIoN FEE
L T .
FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
C EC
,
DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANYCITY ORDINANCE
_
UTYT.ENF ... E ANY ORDINANCE PROVISION.
on LIMIT IN ANYWAYTHE CITY S ABILITY TO ENFUHUL AN! IN G P o I I .
.
TOTAL A..UNT DUE
T.
I HEREBY ACKNOWLEDGE THAT: H E READ THIS APPLICATION. THAT THE INFORMATION
AV
T F
GIVEN IS CORRECT. AND THAT AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
WITH CITY AND STATE LAWS REGULATING CONS7RUC
THE OWNER. I AGREE TO COMPLY I Go , P G
CALL
C
TIOI,L AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
" T F. T, T
WASHINGTON RELATING TO
0 1 S :CTI(
FOR INSPECTR
IN VI DILATION OF THE LABOR CODE OF THE STATE OF
WORKMEN $ COMPENSA�WWSURANCE WDRCW 11 .27.
DATE SIGNED
(425)
771-0220
r
EXT 1333
I ATTENTION
! It IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
1 A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI.
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
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F;,TIALS SIGNATURE DATE
ELEASED BY DATA
GRIGINAL-FILE - YELLOW. INSPECTOR
PINK -OWNER - GOLD - ASSESSOR