20030018.pdfI
DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
CAK�r JOWAIIA
MAILING ADDRESS
(09&& 1190,
CITY ZIP TELEPHONE
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ADDRESS
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NAME
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NUMBER
SUITE/APT#
PLAT NAME/SUBDIVISION NO.
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LOT NO.
LID NO.
LID FEE S
TESCP Approved
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
FEXISTING
RW Permit Requited
street use Permit Req-d
- PROPOSED
Inspection Requited
Sidewalk Required
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STATE LICENSE NUMBER cArinnity- -
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PROPERTY TAX OUNT PARCEL NO.
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LP RESIDENTIAL
PLUMBING / MECH
ADDITION
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COMPLIANCE OR
El CHANGE OF USE
0 REMODEL
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1:1 SIGN
REPAIR
0 GRADING
CYDS
[3 FENCE X
FT)
DEMOLISH
TANK
1:1 OTHER
0 GARAGE
CARPORT
RETAININGWALL
ROICKERY
0 FIRE SPRINKLER
FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVrM EXPLAIN: 13-F9.
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HEAT SOURCE GLAZING % LOT SLOPE %
PLAN CHECK NO: VESTED DATE
THIS PERMIT AUTHORI=S ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 100 DAYS
PERMIT LIMM I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
*APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
IN INTEREST, AGREES TO INDEMNIFX DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS. EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT; AND THAT I AM THE OWNER. OR 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 THEREBY. NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
8fi)t4TURE (OWNER O<AGEN"T) ATE SIGNED
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SEPA REVIEW
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ALLOA
jectrIcal Permit frOul
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SHORELINE OR ADB#, INSPECTION BOND
REO'D POSTED
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61-GN AREA HEIGHT
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OCCUPANT
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Descdptlon
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FEE
Description
FEE
Plan Check
State Surcharge
Building Permit
City Surcharge
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Plumbing
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Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt #
Landscapeinsp.
Total Amt. Due
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100
Recording Fee
Receipt #
1912— 914—
CALL
FOR INSPECTION
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771-0220
EXT 1333
APPLICATION APPROVAL
This application is not a permit until signed by the
Building omciai or histher Deputy: and Fees are paid, and
receipt Is acknowledged lit space provided.
OFFICIALS $IGNAT)JRIE TE
RELEAS I ED - B . Y DAYE
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r% I I 1 81%05 V
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL - FILE YELLOW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK - OWNER GOLD - ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
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"DATE RECEIVED
PERMIT EXPIRES
USE PERMIT
ZONE
CITY OF EDMONDS NUMBER
CONSTRUCTION PERMIT APPLICATION JOB SUITEIAPT#
ADDRESS
OWNER NAME/NAME OF BUSINESS
pLAT NAME/SUBDIVISION NO. LOT NO. LID NO,
CAK�r JOPMAt� I LID FEE S
MAILING ADDRESS ftbur j�i_p_roved
PUBLIC GHT OF WAY PER OFFICIAL STREET MA aw Phrfnil
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CITY ZIP TELEPHONE EXISTIN jjjgqfj6WPqf— 1" go-go wale 1 8
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OWNER/CONIRA-
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NAME CBL"
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DATE
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ZIP TELEPHONE
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BOND,
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EXPIRATION DATE
VARIANCE OR CU
REO'D POSTED
SHORELINE OR ADB# INSPECTION 1$
1[3YEs
STATE LICENSE NUMBER
13NO
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SEPA REVIEW
SIGN AREA HEIGHT
PROP ERTY TAX ACCO
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ADDITION
COMPLIANCE OR
COMMERCIAL 0 CHANGE OF USE
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REVIEWED BY DATE
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GARAGE
CARPORT
RETAININGWALL F RE SPRINKLER
ROOKERY 13 FIRE ALARM
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(ME OF USE. BUSINESS OR ACTIVrM EXPLAIN: 4qVg,.
CHECKED BY TYPE
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DESCRIBI! WORK TO BE DONE
REMARKS
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FEE Description FEE
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Plan Check
State Surcharge
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HEAT SOURCE
GLAZING %
LUS OLUrr
Building Permit
City Surcharge
PLAN CHECK NO:
VESTED DATE
Plumbing
Mechanical
THIS PEnurr AUTHORIZEB ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
2
DOMAIN (CURBS, SIDEWALKS. DRIVEWAYS. MARQUEES, ETC.) WILL REQUIRE
:3
9
SEPARATE PERMISSION- i
f.
'E09V Review
IERMITAPPLICATION: 180DAYS
IT UMM I YEAR - PROVIDED WORK 18 STARTED WITHIN 100 DAYS,
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
-APPLICANT, ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
Fire Review
Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt N
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
Landscapainsp.
Total Amt. Due
iDEEMED
NOR LIMIT IN ANY WAY THE CnyS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee
Receipt #
'0i
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION
APPROVAL
GIVEN IS CORREM AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
CALL
This application Is not a permit until signed by the
Building Official or hisrher Deputy: and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
receipt Is acknowledged In space provided.
WORKMENS COMPENSATION INSURANCE AND RCW 18.27.
OFFICIALS SIGNATURE D TE
RE (OWNER ON
Sp"TU (1_1GEN-n
DATE SIGZND
(425).,,
I
771-0220
E
RELEASED BY C—"/
A-17TEATION
EXT 1333
IT Is UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL - FILE YELLOW - INSPECTOR
A
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK -OWNER GOLD -ASSESSOR
PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
04/02