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[PERMIT
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USE PERMIT
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CITY OF EDMONDS NUMBER
CONSTRUCTION PERMIT APPLICATION JOB SUITE/APT#
ADDRESSl-L I
OWNER NAME/NAME OF BUSINESS
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
Co wfl Ij / FOCA WA SW10,10
MAILING ADDRESS LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved
wl"w RW Permit Required
CITY EXISTING :Z PROPOSED Street Use Permit Reqd
ZIP ELEPHONE Inspection Required
Sidewalk Required
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LN REQUIRED DEDICATION— Fr Underground
Wking required CI
NAME METER SIZE
LINE SIZE�
NO. OF FIXTURES
PRV REQUIRED
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ADDRESS REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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ENGINEERING REVIEWED BY DATE
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ANCE OR SHORELINEORADBI INSPECTION OND
STATE LICENSE NUMBER EXP 0
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SEPA REVIEW SIGN AREA HEIGHT
PROPERTY TAX ACCO NT PARCEL NO. COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED
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LOT COVERAGE REQUIRED SETBACKS (FT)� PROPOSED SETBACKS (Fr.)
NEW RESIDENTIAL PLUMBING MECH
ALLOWED PROPOSED FRONT SIDE REAR FRONT URSIDE REAR
COMPLIANCE OR
ADDITION COMMERCIAL N(,
CHANGE OF USE IV6
PARKING -LOT PLANNING REVIEWED BY DATE
REMODEL MULTIFAMILY SIGN RECID PROVIDED AREA
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REPAIR GRADING CYDS j FENCE 44
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oGARAGE FIETAININGWALL FIRE SPRINKLER
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ROCKERY FIRE ALARM
(ME OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
CHECKED BY TYPLOF[ONSTRUCTION CODE OCCUPANT
GROUP
NUMBER RUMBER OF AL r
OF DWELLING 3 SPECIAL INSPECTION JAREA OCCUPANT
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STORIES &
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DESCRIBE WORK TO BE DONE C5
REMARKS
P8 GRE S INSPECTIONS PER UBC 1108/FINAL INSPECTION REO-0
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Description FEE Description FEE
Plan Check
State Surcharge
HEAT SOURCE
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LOT SLOPE % ding Permit
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City Surcharge
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PLAN CHECK NO.
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VESTED DATE Plumbing
Mechanical
THIS PERMIT AUTHORIZES 014LY THE WORK NOTED. THIS PERMIT COVERS WORK TO
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BE DOME ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN Grading
(CURBS, SIDEWALKS, DRIVEWAYS. MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMITAPPLICATION: IGO DAYS
PERMIT LIMM I YEAR - PROVIDED WORK 15 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 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 PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
41-12 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscapainsp. Total Amt. Due
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NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee Receipt #
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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 APPROVAfr-
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- This application Is not a permit until signed by the
CALL
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED Building Official or his/her Deputy: and Fees are paid, and
14-kiOLATION
OF THE LAqgjAQDE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt Is acknowledged In space provided.
"RV,jAEN'S.$0MPENU�M INDMCE AND RCW 18.27.
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IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL,FILE) YELLOW-11 SPEC -(OR
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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--RE-INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
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Occupancy established by this certificate: Dwelling Units: INW* No. Stories: I
A3 Type.. Construction: VN Sprinkle Basement: No
'U.B.C. 1002)
Maximum Occupant Load .50" (Per,
d- t temain posted at ag times.
Room capacity signs, WKd1jfpqui,re m0s
CA 90620
Owner of Building: Welcome Market Inc. Address: 628f',R—dq10 AVienlbe,' Buena Park,
THE Pochi Tea Station HAS BEEN INSPECTED AND APPROVED AS COMPLYING WITH THE REQUIREMENTS OF THE 1997 EDITION OF
THE UNIFORM BUILDING CODE AS ADOPTED BY THE CITY FOR THE GROUI? AND. DIVISIOWOF OCCUPANCY AND THE USE FOR WHICH THE
PROPOSED OCCUPANCY IS CLASSIFIED.
Issued this 8th day of..��ua 2004
CHIEF BUILDING OFFIC'IAL
BY:
This ce6ficate shall be posted Ina conspbms public area and shall not be removed, mutilated or obscured 8�dh Vbe maintained in legible condition at all times. Any change ofoccupancy oruse requires a building permit and anew
Certificate of occupancy issued by the City of Edmonds Building Official.
AAA I.A.1 'AM :4% 'Al 1-M "M 141
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