20030373.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
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CITY ZIP ITELEPHONE
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NAME
ADDRESS
CITY ZIP ITELEPHONE
NAME CBLN-
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ADDRESS c!0f1._
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CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE
1ORS11 Z�FS . d�"-cJ
PROPERTY TAX ACCO4NTPARCEL NO.
006 0 -3 LIOW 0 1.5-
NEW
RESIDENTIAL
K PLUMBING / MECH
ADDITION
COMMERCIAL
o COMPLIANCE OR
CHANGE OF USE
REMODEL
MULTIFAMILY
SIGN
REPAIR
rl GRADING CYo,
0 FENCE X
FT)
DEMOLISH
TANK
OTHER
GARAGE
CARPORT
o RETAJNINGWALL
ROCKERY
FIRE SPRINKLER
FIRE ALARM
PERMIT EXPIRES
:2 j I
SE PERMIT
ZONE
NUMBER'
JOB /APT#
ADDRESS 1ZLZ
5
PLAT NAMEISUBDIVISION NO. -TOT No, LID NO.
LID FEE $
TIESCP Approved
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Required
Street Use Permit Rsqd
EXISTING — PROPOSED Inspection Required
Sidewalk Required
REQUIRdD PEQICj%TIQN_ FT
W_9r*q__ Lj
METE' 'Z§ta LINE UIRED
ta Labor& Industri ; YES NO
REMAR z
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONin I
(TYPE OF USE, BUSINESS OR ACn3EM
NUMBER NUMBER OF CRITICAL
OF DWELLIN AREAS
STORIES UNITS NUMBER
DESCRIBE WOWTO BE DONE I
6-7a,5 fIlle 7L0
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ENGINEEFJ%Rt"Dot 005"Cul -_ JATE
Is on a hot water 'tanks P r
tfipuWad
FIRE REVII'WN000. h1U ul
VARIANCE OR CU
SHORELINE ORADIIN
INSPECTION
BOND
REO'D
I
POSTED
I
13YEs 13NO
S
SEPA REVIEW
SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
XP ,
,
,
LOT COVERAGE
FT.
S (FT)
hLLOWE
ffEOUIRED �SETBACKS
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CHECKED BY ITYPE ON CQM7 OCCUPANT
I I GROUP
SPECIAL INSPECTION AREA OCCUPANT
REQUIRED 3 LOAD
[13YES 2.1p
REMARKS
VALUATION
$
Description FEE Description
Plan Check State Surcharge
REO'D
FEE
SOURCE
GLAZING IL
WT SLOPt
Building Permit
Ci"urcharge
PLAN CINECK NO--"
VE&fE6 DATE
Plumbing
Mechanical
THIS PERMIT AUTHOREMS ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY 0ONSTRUCTION ON THE PUBLIC
Grading
2 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMITAPPUCATION: ISO DAYS
PERMIT LIMM I YEAR - PROVIDED WORK 16 STARTED WITHIN 180 DAYS
Engr. Inspection
SEE BACK OF P114K PERMIT FOR MORE INFORMATION
'APPLICAK 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 #
ALL CLAIMS FOR DAMAGES OF WHATEVER MATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMfr. ISSUANCE OF THIS PERMIT SHALL NOT BE
Landscapoinsp.
Total Amt. Due
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CnYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
Recording Fee
Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
APPLICATION
APPROVAL
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-
CALL
This application is not a permit until signed by the
TiON; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
Building Official or his/her Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
receipt Is acknowledged In space provided.
WORKMENS COMPENSATMMff%�RANCE AND RCW 18.27.
OFFICIALS S�IGN4URE 9ATE
BIG R OW RO E N"T)
DATE SIGNED
(425)
7MKII?
au� -& 1
:!5 -
771-0220
Te
REVEASED BY
ATTENTION V
EXT 1333
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
FINAL PROJECT APPROVAL FORM
TO:
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Sign
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