20030503.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
ER NAMEINAME OF B
0 �.;Q
I I tc 6
ING ADDRESS
�_-b Z30k J 7 IS'
CITY ZIP TELEPHONE
Lf ox It 7- Y
NAME
ADDRESS
CITY ZIP ITELEPHONE
NAME ICBL#
;-=4
CITY
ZIP I TELEPHONE
USE
ZONE
— __j
Of [PERMIT EXPIRES
PERMIT
4NUMBER
JOB
ADDRESS
a
PLAT NAMEISUBDIVISION NO.
LOT NO.
LID NO.
LID FEE S
TESCP APP(0"Cl
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW Permit Required
street Use permit R&q'd
EXISTING — PROPOSED
inspection Required
Sidewalk Required
REQUIRED DEDICATION FT
UndaMmund
Wirino required 13_
METER SIZE
LINE'��
NO. OF FIXTURES
PRV REQUIRED 3
YES 13 NO 13 3
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE
lZ
-_ I ---
STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY
VARIANCE OR CU SHORELIINEORADBI i INSPECTION BOND
REO'D POSTED
I
[3YEs f6o 1$
SEPA REVIEW
SIGN AREA HEIGHT
PROPERTY TAX ACCOUNT PARCEL NO
COMPLETE EXEMPT
LLCI�%W PROPOID ALLOWED , PR 0
7
P./
,
6' 1`41A Lu)lfq
EXP
NEW
RESIDENTIAL
PLUMBING/MECH
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (Fr.)
FRONT SIDE REAR FRONT URSIDE REAR
ADDITION
Wr COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
REMODEL
MULTIFAMILY
SIGN
PARKING LOT AREA PLANNING REVIEWED BY DATE
REQD
�PROVIDED
7/
REPAIR
GRADING
CYDS
FENCE X
FT)
REMARKS
DEMOLISH
0 TANK
OTHER
0 GARAGE
RETAINING WALL
FIRE SPRINKLER
CARPORT
ROCKERY
FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
'::�
'c7AAL—
CHECKED BY
OCCUPANT
AmAdZI 5
4!5/z)r—/C L�-
ITY=N
GROUP 6
NUMBER
OF
NUMBER OF
DWELLING
CRITICAL
AREAS
SPECIAL INSPECTION OCCUPANT
STORIES
UNITS
NUMBER /V1A
JAREA
REQUIRED [3 YES
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REG'0.
11A A J G
A C
gr A__
/d;�'JO
Af
wy
1.�
led,6v J11OMS PWA-Vf
/
W 162'
t? 0 W Z j!51 //
"
VALUATION
I /w/ f
P
$
1 1
Description
FEE Description
1
FEE
Check
90.—
-ifPlan State Surcharge
,:
HEAT SOURCE
LAZING
LOT SLOPE %
Building Permit I
City Surcharge
PLAN CHF:f"r
VESTED DATE
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
9 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
3
SEPARATE PERMISSION.
t —
Engr. Review
PERMITAPPLICATION: 100DAYS
IL PERMIT UMM I YEAR - PROVIDED WORK 18 STARTED WITHIN 180 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 IND21INIFY, 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 NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
Landscapelnsp.
Total Amt. Due
DEEMED TO MODIVY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITTS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
I—
Recording Fee
Receipt #
IAZ221A
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION
APPROVAL:
GIVEN 13 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
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
Building Official or his/her Deputy: and Fees are paid, and
receipt Is acknowledged In space provided.
WORKMEN's COMPENSATION INSURANCE AND RCW 18,27.
OFA91ALS SIGNATURE DATE
DATE SIGNED
r___P
fA99 i
771-02 20
RNELA
Ef) 6r /DAT
ATTENTION
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
z
0
M