20030969.pdfDATE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
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CITY ZIP =TELEPHONE
NAME
ADDRESS
CITY ZIP TELEPHONE
NAME CBL#
F,
ADDRESS
;1,31
CITY
ZIP TELEPHONE
EF,Fr i
PERMIT EXPIRES
USE PERMIT
ZONE 121 611r� NUMBER
JOB 'j SUITE/APT#
PLAT NAMEISUBDIVISION NO.
LOT NO.
LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
7ESCP Approved
RW Permit Required
Street Use Permit Req'd
EXISTING - PROPOSED
Inspection Required
Sidewalk Required
REQUIRED DEDICATION- FT
underground
Wiring required 13
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
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YES13 NO C3 F
REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE I
ENGINEERING
DATE
I( R;MD 0(/ DATE
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CE OR CU SH rf�i BOND
CVINEORADB INSPECTION
JOY . N I REO'D I POSTED
VIN 13YEs ONO $
SEPA REVIEW SIGN AREA HEIGHT
COMPLETE . EXEMPT ALLOWED . PROPOSED I ALLOWED . PROPOSED
NEW RESIDENTIAL
PLUMBING / MECH
LOT COVERAGE REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (Fr.)
REAR FRONT UR SIDE REAR
ALLOWED PROPOSED FRONT SIDE
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ADDITION
OMMERCtAl.
COMPLIANCE OR
0 CHANGE OF USE
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PAR KING LOT AREA PLANNING REVIEWED BY DATE CL
REMODEL
MULTIFAMILY
SIGN
REQ'D I PROVIDED
0 REPAIR
GRADING
CYDS
FENCE X
FT)
REMARKS
DEMOLISH
13 TANK
OTHER
GARAGE
-1 RETAININGWALL
11
RE SPRINKLER
;tFIRE ALARM
CARPORT
ROCKERY
UWE OF USE. BUSINVSS OR ACTIVITY]I EXPLAIN:
CHECKED BY OF CONSTRUCTION CODE OCCUPANT
ITYPE
GROUP
NUMBER
OF
NUMBER OF
DWELLING
LLI G
"X,4�NUMBER
CRITICAL
RiT
AREAS
RE�
&�A
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SPECIAL INSPECTION AREA OCCUPANT
LOAD
STOR ES
UNITS
UM
REQUIRED
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DESCRIBE WORK TO BE DONE
REMARKS 'D
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REG
Hon,
VALUATION
$
Description FEE Description FEE
Plan Check
State Surcharge
HEAT SOURCE
GLAZING %
1
LOT SLOPE %
Building Permit
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City Surcharge
PLAN CHECM
VESTED DATE
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
1= BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CLIFIRS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMITAPPUCATION: 180DAYS
IL PERMIT UMM 1 YEAR - PROVIDED WORK IS STARTED WITHIN 150 DAY3
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. Depos',
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
a EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
ALI. CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
Landscapainsp.
Total Amt. Due
DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CITYS 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 CORRECT, AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
�E OWNER. I AGREE TO COMPLY WITH CITY A14D STATE LAWS REGULATING CONSTRUC-
/T.
CALL
This application Is not a permit unW 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
Bull Fees are paid. and
ding Official or his/her Deputy: and
facelpt Is acknowledged in space provided.
\WORKMEN'S COMPENSATIO��NCE AND RCW 18,27.
OF DATE
TURE (OWNER 0 GEI"Mi
DATE SIGNED
1A 5)
1-12
WCIIGN7A7.
14
771-0220
ed
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BY /bATE
ATTENTION
EXT 1333
k_&�
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 - INSPfci6R
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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MEMORANDUM
I I d L I P f
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P P I
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Date. 12/02/03
L I
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Too Debbie Karbert Accounting Assistant
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Marie Harrison
From,,
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liltr UND
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uld be $260.00
1 0 1 k L I I d
4. 1 r Debbie, plemase prepare a refund check in the amount of $397.00. The funds sho
S;�
Please mail the check to Federal
.,J� t 0
I p building, $128oOO plan check
and $9*00 State surcharge,
I k I
th 6. The licant overpaid
:if 00, Lynnwood, WA 9803 upp
"t'. P I I
I L J k I ff"=2
Firesafety Inces 1923136 Avenue W,
If "tJ%'X 1P.
4 ords. Thank you.
ip
't-, P
ermit fees
p I have enclosed a copy of our recei t #23212 for your rec
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Sincerely,
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d" t. V Director2s Signature
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City of Edmonds CA COMMUnity S rvices
FINAL PROJECT APPROVAL FORM
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Si
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DATE RECEIVED
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Q PERMIT
-F EXPIRES
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CITY OF EDMONDS
USE PERMIT
ZONE NUMBER
CONSTRUCTION PERMIT APPLICATION
JOB
ADD��
OWNER NAMEINAME OF BUSINESS
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
6+e f V, f I
MAILING ADDRESS
LID FEE S
173,�ao
TIESCP Approved
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW PenrAt Required
street Use Pannit Rsqd
CITY ZIP �JTELEPHONE
EXISTING — PROPOSED Inspectlon Wulred
Sid&w&lk R@quked
REQUIRED DEDICATION— FT U
Wiring req
NAME
METER SIZE LINE SIZE I NO, OF FIXTURES pRV REQUIRED
YES 13 NO 13
ADDRESS
REMARKS
OVINER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
CITY ZIP _rIEPHONE
NAME ICB.L
IENGINEERING
REVI=EWED DATE
ADDRESS
3 1 2 —Ave - tv
in
CITY ZIP TELEPHONE
F E R 0 B DATE
to x
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NCE OR CU SHOrNEORADB# INSPECTION BOND
V7
ST TE LICENSE NUMBER EXPIRATION DATE I CkWCKED BY
REO'D POSTED
1$
i4t
13YEs ONO
PROPERTY TAX ACCOUNT PARCEL NO.
SEPA REVIEW SIGN AREA HEIGHT
COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED PR OPOSED
, , ,
too
EXP
0 NEW RESIDENTIAL 0 PLUMBING / MECH
LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (Fr.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT LIRSIDE REAR
ADDITION OMMERCAL 1:1 COMPLIANCEOR
OF USE
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CHANGE
REMODEL MULTIFAMILY 0 SIGN
PARKING LOT AREA I PLANNING REVIEWED BY DATE
REIID I PROVIDED
CL
GRADING FENCE
REPAIR CyDS X_FT)
REMARKS
OTHER
0 DEMOLISH TANK
1 r. E
3 GARAGE RETAININGWALL FIRE SPRINKLER
XFIREALARM
-
CARPORT ROCKERY
OWE OF USE. BUSiN jcTiVTM EXPLAIN:
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/OF
CHECKED BY ITYPE OF CONSTR CODg OCCUPANT
0./ GROUP
L
NUMBER WWR RIT4C
Of U A
li3 TNA
SPECIAL INSPECTION AREA OCCUPANT
LOAD
STORIES T;
REQUIRED [3YES j
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INS ECTION REaD
Add Fion 74 vipeA7 -w
1�1�45 /q1&47_
VALUATION
$
Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %
Building Permit City SurchargeI 1,5.
PLAN CHECM VESTED DATE
Plumbing
�5_-37
Mechanical
THIS PERMIT AUTHORRES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, UARGUEES. ETC.) WILL REQUIRE
SEPARATE PERMISSION.
t:
Engr. Review
PERMITAPPILICATION. 180 DAYS
PERMIT LIMM I YEAR - PROVIDED WORK IS STARTED WITHIN 1130 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 r,,':Io5 Plan Chk. Depos: AvIll
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 PERMrT. ISSUANCE OF THIS PERMIT SHALL NOT BE
Landscapeinsp. Total Amt. Due _t!�5L�
DEEMED TO MODIFX WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITYS 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 CORRECT. AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH C17Y 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
Building OtkW or hisMer Deputy: and Fees we paid, and
FOR INSPECTION receipt In acknovdodgod in space provided.
WORKMENS COMPENSATI AND RCVV 18.27.
C DATE
IE (OWNER RAGENT) DATE SIGNED
�ja
(425)
(4C
771-0220 /DATE
UIED BY
ATTENTION
EXT 1203 1�16
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 YEILILCOWN - INS E
CATE OF OCCUPANCY HAS BEEN GRANTED. UBc SECTION 109
PINK -OWNER GOLD -ASSESSOR
i GREEN - ACCOUNTING
04/02 K0
PRESP," ,"q�/YOU ARE MAKING 5 COPIES
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