20030870.pdfM
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
ER44AMEMME OF BUSINESS 11-1
MAILING ADDRESS
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CITY ZIP TELEPHONE
j F, 1,*,*) 2- /W,, 6 - 7 —16 -
NAME
ADDRESS
CITY ZIP
NAME A') -1 � ICBL#
PERMIT EXPIRES
USE PERMIT
ZONE NUMBER
JOB SUITE/APT#
ADDRESS
&Z
PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID FEE f
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP App"rv*d
RW Nrn* Rewired
street use Perinx Wd
EXISTING — PROPOSED
Intipwtion Rowifsod
SidirwalkRequired
REQUIRED DEDICATION— FT
_T_
Undotirmod
Whtngtaquired 13
METER SIZE
LINE SIZE
0, OF FIXTURES
PRV REQUIRED
1
f
YES 13 NO 13 z
I
REMARKS
I
OWNERMONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
R
ADDRESS
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APIU--S!iURI�kL,�GULATORVALVE(PKV)
oil
in a Ki . V Q'r il�l "1111i� I." AD
FIRE REVIEWED BY
-
THE WATER SHL)TOFF DATE
CITY
ZIP TELEPHONE
VARIANCE OR CU
SHORELINE OR ADB# IN PECTION BOND
STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY
REO'D POSTED
113YEs is
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13NO
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I - SEPA REVIEW
SIGN AREA HEIGHT
PROPERTY TAX ACCOUNT PARCEL NO.
COMPLETE EXEMPT
ALLOWED PROPOSED , ALLOWED PROPOSED
7z'90
,
,
re
EXP
NEW
XRESIDENTIAL
1W FLUMBING/MECH
LOT COVERA
ALLOWED PROPOSPRI
APPIl $151) SETBACK$ (Fr.)
lAyff SgWjfMRSj ftylf""LIR SIDE REAR
ADDITION
COMMERCIAL
COMPLIANCE OR
0 CHANGE OF USE
SHAM
BE INSTALIXEII 0N:TM
PARKING U109kawl
Tffil�fa"LDINWTE
REMODEL
MULTIFAMILY
SIGN
REOD I PROVIDED
REPAIR
GRADING
CYDS
FENCE X
FI)
REMARKS
DEMOLISH
11 TANK
OTHER
GARAGE
CARPORT
[3 RETAINING WALL
ROCKERY
FIRE SPRINKLER
FIREALARM
(TYPE OF USE. BUSINESS 0�14 CT LAIN:
CHECKED BY TYPE
N OCCUPANTX5
GROUP
c2t
NUMBER
OF
NWUM 'R OF
E BE
D ILLING
RITICAL
AREAS
SPECIAL INSPECTION JAREA OCCUPANT
STORIES
N
- _,A) ITS
N UMBER
REQUIRED [3 YES
LOAD
DESCRIBE WORK TO Bf 60NE
REMARKS
PROGRESS INSPECTIONS PER UBC 100/FINAL INSPECTION REO'D
Aw-, e, , �_
I
is
M
$
Descriptlon FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE
GLAZING %
LOT SLOPE %
Building Permit
City Surcharge
PLAN CHECK NO:
VESTED DATE
I
Plumbing
I
Mechanical
THIS PERMIT AUTHORGMS ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
It: BE DONE ON PRIVATE PROPEIRTY ON101 ANY CONSTRUCTION ON THE PUBLIC
Grading
2 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, UARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERUTT APPLICATION: ISODAYS
a. PERMIT UMM I YEAR - PROVIDED WORK IS SYARTED 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 INWRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
Landscapelnsp.
Total Amt. Due
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CnY8 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 CORREM 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 THE BOR 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' M NSATION INSURANCE AND RCW 16.27.
OFFICIALSI S19NATUYE
SI:NATURE �OWER R AG]
DATE SIGNED
00-3
(425)
9— _o� i & � 9
A�4
MMM
MOO 4-
& �j
771 0
-022
t
RELEASED By 1 DATf
A'I'TENTION
Off 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
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ION
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A JDATE RECEIVED
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PERMIT EXPIRES
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USE PERMIT
CITY OF EDMONDS
ZONE
NU BER
CONSTRUCTION PERMIT APPLICATION
JOB RESS
ADD
SUITE/APT#
E OF BUSINESS
PLAT NAME/SUBDIVISION NO. T
LID NO.
MAILING ADDRESS
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW pe=&d
Stmet 11180
CITY ZIP TELEPHONE
EXISTING — PROPOSED
Use Formit
k4pection Roqtkw
SidrmaltRequimd
REQUIRED DEDICATION— FT
U'x%rWWW
Wwg req*ed
NAME
METER SIZE LINE SIZE S
PRV REQUIRED
YES 13 No E3
z
ADDRESS
REMARKS
OWNERICONTRACTALRMOKSI*W-%E�i��RAINA�GE
CIT'Y ZIP TELEPHONE
LUAIML&
VVIIII 6616W
n
NAME6
ICSL#
ENGINEERING REVIEWED BY
DATE
ADDRESS
P1 Tr, �q I TA TqT TO
20
us
FIRE REVIEWPPPF.MLjfWR WULMRVALVEMM
CITY ZIP TELEPHONE
SHALL BE INSTALLED NEAR
1z
M
VARIANCE OR CU
BOND
STATE LICENSE NUMBER EXPIRATION DATFTCHECKED BY
REOD POSTED
10YEs
E3No is
PROPERTY TAX ACCOUNT PARCEL NO.
SEPA REVIEW SIGN AREA
COMPLETE EXEMPT ALLOWED PROPOSED
HEIGHT
ALLOWED PROPOSED
1 1W
6
,
,
iVeo
EXP
P
NEW RESIDENTIAL LUMBING MECH
LOT COVERAGE REQUIRED SETBACKS (Fr.)
ALLOWED PROPOSED FRONT SIDE REAR
PROPOSED SET13ACKS (FT.)
FRONT LIRSIDE REAR
COMPLIANCE OR
UAW TO UPC
.2
COMMERCIAL
ADDITION CHANGE OF USE
REMODEL muLnFAmwy SIGN
PARKING
RECID ��! 'ROV BE
DATi
9L
o FENCE
REPAIR GRADING CYDS X FT)
ME STM1BUffiDM:
REMARKS
[3 DEMOUSH MK OTHER
0 -GARAGE [3 RETAININGWALL FIRE SPRINKLCR
CARPORT ROCKERY FIRE ALARM
M?E OF USE, BUSINESS LAIN:
CHECKED BY
OCCUPANTP
GROUP
W_
NUMBER NUMBER OF CRITICAL
OF DWELLING AREAS
—1—AREA
SPECIAL INSPECTION
OCCUPANT
STORIES UNITG NUMBER
REQUIRED [:] YES
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS PER UBC 108/11FINAL INSPECTION REGID
wo6 11:'-&-�j I'Al'id
z
0
0
M
M
M
0 C
Irn
to
C
Irn
8C Fon
_-A L n;
I L/
VALUAnON
$
Description
FEE Description FEE
z
Plan Check
state Surcharge
0
HEAT SOURCE GLAZING % LOT SLOPE %
Building Permit
city Surcharge
M
PLAN CHECK NO: VESTED DATE
Plumbing
Mechanical
THIS PERMrr AUTHORIZE ONLY THE WORK NOTED. THIS PERMIT COVER8 WORK TO
t: BE DOME ON PRWATIE PROPERITY ONLX ANY CONSTRUCTION ON THE PUBLIC
Grading
3 DOMAIN (CURSS, SIDEWALKS, DRr&VAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSICHN.
Engr. Review
PERMITAPPUCATIOW 1180DAY8
PERUFF IUMM I YEAR - PROVIDED WORK IS STARITED WITHIN 180 DAYS
Engr. Inspection
SEE 13ACK OF PINK PERMrr FOR L40RE INFORMATION
*APPUCANT, ON BEHALF OF 108 OR HER SPOUSE, HEIRS, ASSIGNS AND'SUCCESORR-1.
Fire . Review.
Plan Chk. Dermit
IN INTEREST. AGREES TO INDEMNIFY; DEFEND AND HOLD -HARMLESS TH1!..Cn`Y` OF
7
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 PERMTE ISSUANCE OF THIS PERMIT SHALL NOT BE
Landscapoinsp.
Total Amt. Due
DEEMED TQ MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IV AW WAY THE CITY-S ABILITY TO ENFORCE AW ORDINANCE PROVISION.-
Receipt #
Recording Fee
I HEREBY A DGE THAT I HAVE REM THIS APPUCATION; THAT THE INFORMATION
REBY A 'i
APPLICATIO N APPROVAL
GIVIEN Is Cr AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
IS C�
THE OWNER. I REE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
E I I
WN'R
CALL
This i application Is not a permit until signed by the
TIOW, AND IN NG THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
�j
.0 MD NG
IN VIOLATIO THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
1 0 TIO
N Vi
Building Official or his/her Deputy: and Res are paid, and
FOR INSPECTION receipt is acknoyAodged in space ptovided.
ALA"rH
WORKMEN SATION INSURANCE AND RCW 16.27.
M
C
OFFICIALS S19NATUVE I TE
SIGNATURE ER R AGEPJ�� DATE SIGNED
00.3
(4255)
AA
771-0220
BY DATA
VC
EXT 1333
IRELEASED
IT is U FuL TO USE OR OCCUPY A BUILDING UNTIL,
NLAW
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
GREEN - ACCOUNTING
1,04/02 PRESS HARD -YOU ARE MAKING 5 COPIES