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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
F"AMEINAME OF BUSINESS
MAILING ADDRESS
P�1511
CITY zip TELEPHONE
ed�s t7900 I
NAME
ADDRESS
CITY ZIP I TELEPHONE
NAME
PERMIT EXPIRES PALI In T
USE
ZONE PERMIT
NUMBER
JOB E/APTN
ADDRESS
PLAT NAM EISU BDIVI SION NO.
LOT NO.
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Pormit Required
Street Use permit Req-d
EXISTING - PROPOSED
inspection Required
Sidewalk Required
REQUIRED DEDICATION � FT
Underground
Wiring required
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES 0 NO 0
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ui
ENGINEERING PIEVIEWED/DATE
cc ADDRESS
102
L) toloo
9 FIRE REVIEWED BY DATE
CITY ZIP:. TELEPHONE
a:
0 --ejs
VARIANCE OR CU SHORELINE OR ADB# INSPECTION BOND
STATE LICENSE NUMBER EXPIRATION DATE REO'D [POSTED
IZTMDb [3 YES [3 NO
HEIGHT
zi EPA REVIEW SIGN AREA
PRQPIUY TAJ( jrCCO TP N COMPLETE I EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED
J0
/sit'
i.,
EXP
NEW RESIDENTIAL LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
PLUMBING MECH ALLOWED PROPOSED FRONT SIDE REAR FRONT. 1JR SIDE REAR
z
[3 ADDITION COMMERCIAL ci COMPLIANCE OR
CHANGE OF USE
Q
PARKING LOT AREA PLANNING REVIEWED BY DATE
0 REMODEL 0 APARTMENT C3 SIGN REaD I PROVIDED 1:16
0 REPAIR 0 GRADING 0 FENCE
CYDS ( — X � FT) REMARKS
[3 DEMOLISH TANK
o GARAGE 0 R
RMNING WALL
CARPORT ERY 0 RENEWAL
r- (TYt& OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
CHECKIEDLBY e%UCTION Cft40 OCCUPAW^
a
17 L m,0014,"Ir VU
jawwo .... 1 If I
U11 NUMBER NUMBEROF CRITICAL
0 OF DWELLING AREAS SPECIAL INSPECTOR AREA
0 OCCUPANT
0 STORIES UNITS NUMBER REQUIRED 0 YES LOAD
DESCRIBE WORK TO BE DONE
arh 6 REMARKS
b and inSbil
PROGRESS INSPECTIONS PER UBC 1081FINAL INSPECTION REO'D 5
UODD -Fk;�, 60POY j
,.,�eMt 5
ri� I r
RC
VALUATION FEE
PLAN CHECK FEE�
HEAT SOURCE GLAZING % LOT SLOPE %
BUILDING & 57
PLAN CHECK NO: VESTED DATE 'PLUMBING'
MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
s.- BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS. DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE GRADING/FILL
SEPARATE PERMISSION.
PERMIT APPLICATION: 100 DAYS A= SURCHARGE
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
ENG, INSPECTION FEE
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS zoo
IN INTEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF LANDSCAPING
2 EDMONDS. WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
m INSPECTION FEE
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY REC]�z v
' FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE PLAN CHECK DEPOSIT
EEMEDTOMODIFY, WAIVE OR REDULEANY REQUIREMENT OF ANY CITY ORDINANCE
- :
OX0 'NOR LIMIT IN ANYWAY THE CITY'S ABILITY TO ENFORCE ANYORDINANCE PROVISION. RE= FT
see TOTAL AMOUNT DUE I
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 APPLICATION APPROVAI
THE OWNER. I AGREE TO COMPL V WITH CITY AND STATE LAWS REGULATING CONSTRUC- This application is not a permit until signed by the
TION; AND IN DOING THE W THO ZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or his/her Deputy: and Foes are paid. and
IN VIOLATION OF THE L A CODE o rHE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided,
WORKMEN'S COMPENS ON INSURANC AND RCW 18.27.
HO C S RE DATE
E 0
IAN)C
SIGNATURE (OWNER AGENT) DATE SIGNf D (425) t I A
F YA-IW- I/Ag/e3
V.0 =C�/ to 771-0220 DATE
ATTENTION EXT 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION 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
5/98
'7777q
[c
FINAh4ROJECT APPROVAL FO%M,
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FIRE DEPARTNMNT DATE —0
FROM:
ENGINEERING DIVISION DATE
"AMMON
PLANNING DIVISION DATE
gAZI/C,4 /t.4
PROJECT
01-
SITE ADDRESS
# a-066 —,o�4Z_43___ADB# -----PATE INSPECTED-1
DESCRIPTION OF WORK TO BE INSPECTED HOOD ro
IAI
ith approved p
Inns. Final approval
A fleld inspection was conducted to determine final ompliance w
e no objections from the above signed Department to the release of
denotes that there ar
PERFO CE BONDS and the granting of
GRANT FINAL PROM T APPROVAL
inspector
by inspector
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CITY OF EDIV16NDS 1. ZONE
CONSTRUCTION PERIVIft APPLICATION �JOB
F ADDRESS
--mcm fah"PINAMP nF BUSINESS
MAILING ADDRESS
P.')511 __
CITY
t�dmayl
NAME
ADDRESS
CITY
NAME
% , I I I 'd,
PERMIT EXPIRES �J I jj�C4 In -V
PERMIT
NUMBER
1 0 a EJAPTO
hr12611 kC7t-
oiav
PLAT NAM E/SUBDIVI SION NO. 0.
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
LID NO.
LID FEE $
TESCP Approved
RW Permit Required E3
Street Ume Permit Req'd CI
ZIP TELEPHONE
EXISTING - PROPOSED
In"won Required
Sid#wWk Required
0
0
Ft EQUI RED DEDICATION - FT
Underground
Wiring mquIred
0
METER SIZE LINE SIZE 7. OF FIXTURES
PRV REQUIRED
-
YES C3 NO 13
w
REMARKS
E
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
0
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ZIP TELEPHONE
ADDRESS
tfvoc
CITY ZIP TELEPHONE
9 � IDY -�2 CYr-7,;
STATE LICENSE NUMBER EXPIRATION DATE
P7ilvui�. . 4/)yVPL, 11-01-v-3
N EW
0 RESIDENTIAL
ADDITION
COMMERCIAL
0 REMODEL
0 APARTMENT
0 REPAIR
0 GRADING CYDS
0 DEMOLISH
0 TANK
o GARAGE
0 RETAINING WALL
z CARPORT
ROQffBy__
OF USE BUSINESS OR ACTIVITY)I EXPLAIN:
TYA;��
-e
NUMBER
BER OF
OF
DWELLING
STORIES
UNITS
DESCRIBE WORK TO BE DONE
ENGINEERING REVIEWED/DAT E
FIRE REVIEWED BY DATE tu
ENGINEERING Ir
FI RE REVI EWED I
If
0qq0
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ARIANCE OR CU SHORELINE OR ADB# INSPECTION BOND
I REO'D POSTED
S P R �Vj 0 YES C3 NO
E PA --...Ew SIGN AREA HEIGHT
C COMPL T E� I PROPOSED
OMPLETE I EXEMPT ALLOWED PROPOSED ALLOWED
PLUMBING / MECH
COMPLIANCE OR
CHANGE OF USE
0 SIGN
FENCE
Cl ( X FT)
X 0 R
0 RENEWAL
CRITICAL
AREAS
NUMBER
LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
z
PARKING LOT AREA I PLANNING REVIEWED BY DATE 5 1
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CHECKED BY
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SPECIAL INSPECTOR JAREA OCCUPAN
REQUIRED 0 YES LOAD
REMARKS
fe ]rnwwnv- INSPECTIONS PER UBC 1081FINAL INSPECTION
)h'ty?
PLA14 CHECK FEE
HEAT SOURCE GLAZING % LOT SLOPE % BUILDING
VESTED.DATIE
PLAN CHECK NO:
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS W6RK T6
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
0 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
3 SEPARATE PERMISSION.
t:
a
m PERMITAPPUCATION* ISO DAYS
w
CL PERMIT LIMIT: 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 INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
21 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
DEEMEDTO MODIFY.WAIVEOR REDUCE ANY REQUIREMENTOF ANYCITY ORDINANCE
0 NOR LIMIT IN ANYWAYTHE CITYISABILITYTO ENFORCE ANYORDINANCE PROVISION. -
I HEREBY ACKNOWLEDGE THAT I 14AVE 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 COMB6*w4Tjj CITY AND STATE LAWS REGULATING CONSTRUC-
TION; AND IN DOING THE WOa&A4TH0 ED THEREBY. NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE�LrR CODE O�FTHE STATE OF WASHINGTON RELATING To
WORKMEN'S COMPENS ON INSURANC AND RCW 18.27.
[SIGNATURE (OWNER VAGENT) DATE Sit iNED -z
Vb m
ATTENTION
IT IS UNLAWFUL TO USE OR'OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
"W98
GRADINGIFILL
SURCHARGE
ENG. REVIEW FEES
ENG. INSPECTION FEE
LANDSCAPING
INSPECTION FEE
PLAN CHECK DEPOSIT
TOTAL AMOUNT DUE
VALUATION
Z_5
.0
FEE
m
APPLIC ATION APPROVAL
CALL
This application is not a parrnit.unIJIsignedby the
Building 011icial or histher Deputy: and Fees are paid. anb
FOR INSPECTION
receipt is acknowledged In space pro�idod.
(425)
0 C Sit RE T
S
11
771-0220
RELE Y DATE
EXT 1333
771-0221
FAX
ORIGINAL FILE YELLOW - INSPECTOR
PINK - OWNER GOLD - ASSESSOR
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