20030650.pdf4
DATE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEtNAME OF BUSINESS
b&94ETQ 63tO I L L�:y
MAILING ADDRESS
L6(oo t 76rh pj_ W
cirf ZIP ITELEPHONE
-Cbklc*� IMOZ1.0 �215-77(6f610 I
7AME
ADDRESS
CITY
NAME
ADDRESS
CITY
ZIP I TELEPHONE
6 1", >66 r)-,.
STATE LICENSE NUMBER
ZIP
NO.
CBL N
TELEPHONE
EXPIRATION DATE I CFE-CKED BY
NEW
K RESIDENTIAL
ADDITION
0 COMMERCIAL
REMODEL
muLnFAmv
REPAIR
GRADING CYDS
DEMOLISH
TANK
0 GARAGE
ci RETAININGWALL
cARPoFrr
ROCKERY
(TYPE OF USE. BUSINESS OR LAIN:
rATn
e�
PIE3 tho"ce
NUMBER
N UMBER OF
OF 2
DWELLING
STO IES
UNITS
DESCRIBE WORK TO BE DONE
RELOCA'trE K rT - 6,11 M K SL"
PLUMBING/MECH
0
COMPLIANCE OR
CHANGE OF USE
1:1
SIGN
[3
FENCE
FT)
OTHER
FIRE SPRINKLER
0
FIRE ALARM
CRITICAL
AREAS
NUMBER
fl tswv
PERMIT EX PIRE
_9
USE PERMIT 0
ZONE
3�-t% 5
NUMBER
JOB
SUITE/APT#
ADDRESSIs 76-TH PL \A/
-J(
400
PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP AP Od
RW Permit=Ired
Street Use Permit Rsq'd
EXISTING - PROPOSED-
Inspeakm Required
sidewast Required 13
REQUIRED DEDICATION- FT
Und@W"d
Wiring(equired [3
METER SIZE
LINE SIZE
NO. OF FIXTURES
pRV REQUIRED
i
YES13 NO 13 z
I
REMARKS
re
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE 11
REVIEWED BY DATE
FIRE REVIEWED BY DATE
VARIANCE OR CU
SHORELINE Oil ADB*
INSPECTION
BOND
REOD
I
POSTED
I
13YEs ONO
$
SEPA REVIEW
SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
:XP ,
,
I
LOT COVERAGE
REQUIRED SETBACKS (Fr.)
PROPOSED SETBACKS (Fr.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT LIRSIDE REAR
DATE
I
PARKING
I
LOT ARE
PLANNING REVIEWED BY
RE(YD I PROVIDED
CHECKED BY ITYPE OFf4jFUCTIOf 1 C26 OCCUPANT
GROUP jo_
SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED [3 YES LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC 1108/FINAL INSPECTION REO'D
VALUATION
$
I
Description
-_
FEE
Description
FE E
Plan Check
State Surcharge
HEAT SOURCE % LOT SLOPE %
Building Permit
City Surcharge
PLAN CHECK NO: VESTED DATE
Plumbing
Mechanical
THIS PERMIT AUTRORGMS ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS, MARQUEES, FTC.) WILL REQUIRE
3 SEPARATE PERMISSION.
I:
Engr. Review
PERMrrAPPUCATION: ISO DAYS
IL PERMIT UMM I YEAR - PROVIDED WORK IS 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 Clik. 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 NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMrr. ISSUANCE OF THIS PERMIT SHALL NOT BE
Landscapeinsp.
Total Amt. Due-
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CI1YS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
-7
2
Recordi
Receipt # Lu 6
z 191
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APP ROVAL
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
ilica )n Is not a permit until signed by the
floor
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYE
F
nlnpciall hisihor Deputy: and Foes are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING
FOR INSPECTION it
1ptlsackn lodged spacOplolded-.
WORKMEN'VaMK"ION INSURANCE AND RCW 18.27.
SS ATUR DATE
E
81 E AGINM DATEAIGNED
qfvTufi
25
0
f-
771-0220 1 14
6AISIED W D E
'AWE'hN
BY
T (0 N
EXT 1333
)5COPIES
--------
IT IS L_ 70 1 SE OR OCCUPY A BUILDING OR STRUCT RE tUNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A ERTIFI-
ORIGINAL -FILE YELLOW- INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
PINK -OWNER GOLD -ASSESSOR
04/02 PRESS HARD -YOU
GREEN - ACCOUNTING
AM14G
1