20040013.pdf2
DATE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
MAILING ADDRESS
(-1)S—) I I - A "I
CITY
NAME
ADDRESS
CITY
NAME
&Twt A%c,��l
LQ905-/5d4d -21.
CITY
(lilt C(eek K/,,.
STATE LICENSE NUMBER
COO 6 I" -*CS 6�
ZIP ITELEPHONE
IU 2 1 1 PERMIT EXPIRES
USE PERMIT
ZONE
NUMBER 0 q-CO13
JOB SUITE/APT#
ADDRESS IC)o
PLAT NAME/SUBDIVIS ION NO,
LOTNO.
LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW PenTilt Required
Street Use Peffnit A&q'd
EXISTING PROPOSED
inspection Roquired
Sidewalk Required
REQUIRED DEDICATION- Fr
Underground
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
I
YEs13 NO 13 z
REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE_
-el V it, ENGINEERING REVIEWED BY DATE
DATE
9P , ITELEPHONE LO M
. 01
ow VAY11ANCE OR CU f SHOfgLINEORAQB# I� IN5PECTION BOND
EXPIRATION DATE CHECKED FY POSTED
6e-7REO'D
dl'72 &X15- gpq ONO $ HEIGHT
[3 NEW
RESIDENTIAL
ADDITION
OMMEFICiAL
REMODEL
El mummmiLy
0 REPAIR
0 GRADING CYDS
[:] DEMOLISH
[:] TANK
oGARAGE
CARPORT
[3 RETAININGWALL
ROCKERY
"141�F USE BUE IINESS ACTrM EXPLAIN:
e
SE R IEW .1UNIN mncfi!
V COMPLETE , EXEMPT ALLOWED PROPOSED,, PROPOSED
EXP
PLUMBING/MECH LOT COVERAGE REQUIRED SETBACKS (FTY wOPOSED SETBACKS (Fr.)
ALLOWED PROPOSED FRONT SIDE REAR F UR SIDE REAR
COMPLIANCE OR
CHANGE OF USE
PARKING LOT AREA I PLANNING REMVIjMDATE
SIGN REOD
FENCE I 1 4 m
x FT) REMARKS
F RE SPRINKLER
FIRE ALARM
NUMBER NUMBER OF CRITICAL
OF DWELLING AREAS
STORIES 1-UNrFS NUMBER
DESCRIBE WORK TO BE DONE
Wide havid wl
re nii, r
IFCHECKED BY ITYPE OF CONsTnuarm. C-J!�E'
y
SPECIAL INSPECTION JAREA'
REQUIRED
REMARKS,
�ROGRESS INSPECTIONS PER UBC108/FIN
VALUAnON
$
FEE
DescrIpUin EE Description
State surcharge
Plan Chepk 1-� C,
2
OCCUPANT
GROUP
OCCUPANT
LOAD
INSPECTION REG-0
HEAT SOURCE
GLAZING %
-10T,61LOPE %
;' % "
Building'Pprmit
r !
-
City Surcharge
�
PLAN CHECK NO:
VESTED DATE
Plumbing"
Base Fee
124
0
Mechanical
THIS PERMIT AUTHORIZES 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, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: 180 DAYS
13.
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 Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
2
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
Fire Inspection
Receipt #
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
,L_!:R
LIMIT IN ANY WAY THE CITYs ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
Recording Fee
Receipt #
1 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 CITY AND STATE LAWS REGULATING CONSTRUC-
CALL
This applicadon 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
FOR INSPECTION
Building Official or histher DOPuIY: and Fees are paid, and
receipt Is acknowledged In space provided.
WORKMEN'S COMPENSATI�=NCE AND RCW 18.27.
OFFICIALS SIGNATURE DAT
81 TURE W R AGE
DATE SIGNED
1A '35)
V� 0
1/
771-01220
M!:E�SED B DATE
AIMENTION
M 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
—A I/
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL -FILE YELLOW) INSPECTOR
7)
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
PINK -OWNER GOLD -ASSESSOR
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'DDATE RECSIVE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
ER NAME/NAME OF BUSINESS
_Tcc),
MAILING ADDRESS
c loo
CITY ZIP TELEPHONE
S U, ) C.
NAME
ADDRESS
CITY ZIP
TELEPHONE
NAME
OM410(ciil (b451f.0
A��qA-;5)m '.
CBL
9C
ADDRES6
A05-6dvi� ?). �)5
CITY ZIP
Mill 0 (ee)( LJO.. qg0j
TELEPHONE
36kO _%0 BS(A)
STATE LICENSE NUMBER
EXPIRATION DATE
CHECKED BY
CoH61':-aS6jS0C' 1�
0_W�_
PRW�ACCOUNT PARCEL NO.
'T
dz�
NEW RESIDENTIAL
PLUMBING / MECH
ADDITION MMERCIAL
COMPLIANCE OR
CHANGE OF USE
REMODEL MULMAMILY
SIGN
GRADING FENCE
REPAIR CYDS x FT)
DEMOLISH TANK
GARAGE o RETAJNINGWALL FIRE SPRINKLER
CARPORT ROCKERY FIRE ALARM
(TYPE -OF USE, BUSINESS rR ACTIVITY) EXPLAIN:
NUMBER
NUMBER OF
____T_CRfTICAL
OF
STORIES
DWELLING
UNITS
AREAS
NUMBER
DESCRIBE WORK TO BE DONE
E�Nslvll (lei W46e hood L-i"ll',
HEA
T SOURCE GLAZING % LOT SLOPE %
PLAN CHECK NO: VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
HE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMITAPPLICATION. 180 DAYS
PERMIT LIMM I YEAR -PROVIDED WORK IS STARTED WITHIN 160DAYS
SEE 13ACK OF PINK PERMIT FOR IIIIORE INFORMATION
"APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
IN INTEREST, AGREES TO INDEMNIF% DEFEND AND HOLD HARMLESS THE CITY OF
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 PERMrr. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED To MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
I HEREBY ACKNOWLEDGE THAT I HAVE READ TH 8 APPLICATION; THAT THE INFORMATION
IE
GIVEN 18 CORRE" 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-
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTOU RELATING TO
WORKMERS COMPENSATION INSUBANCE AND RCW 18.27.
DATE SIGNED
/") - J� - 0
USE
ZONE
JOB
ADDRESS
7 1 PERMIT EXPIRES I
PERMIT I-),
NUMBER 0(00q_ ()C)
SUITE/APT#
)0
PLAT NAMEISUBDIVISION NO.
LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TFSCP Appriwod
RW PsmVt Required
Street Use Pormll R&Wd
EXISTING — PROPOSED
InspoctlonRequirecl
SidewalkReWired
REQUIRED DEDICATION— FT
I Undorground
jymmingrect ed
METER SIZE
LINE SIZE
I
NO. OF FIXTURES
I
I PRV REQUIRED
YES 13 NO E3
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
ENGINEERING
DATE
Fr
DATE
:Mr/4
?
VA OR CU
SHOOKLINE OR ADS#
I IN�'E&ION
BOND
,$ANCE
theellE 0
POSTED
EIIIIIEP ONO
$
SEPA REVIEW
SIGN AREA
HEIG
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
I
�A_
a
, --:5si
_.XP
LOT COVERAGE
REQUIRED SETBACKS (Fr.)
PROPOSED SETBACKS (Fr.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT LIRSIDE REAR
PARKING
REQ1
LOT AREA]�P_L�ANNING
REVIEWED 13Y DATE
REMARKS
CHECKED BY ITYPE (IF CW
y N c
SPECIAL INSPEC TION AREA
REQUIRED [:] YES
REMARKS
PROGRESS INSPECTIO
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
CTION CO E PANT
GROUP
d dm) I OID2 occu . S_
OCCUPANT
I LOAD 2 4 9
rn
PER UBC 108/FINAL INSPECTION REQ'D
111, A&_9 mob I zM0K9Kz?A__
IN I IN kv I
FEE
Description FEE
State Surcharge
City Surcharge
Base Fee 0
Plan Chk. Depo
Receipt #
Total Amt. Due
Receipt #
CALL
This application Is not a permit unlit signed by the
Building Oftlal or his/her Deputy: and Fees we paid, and
FOR INSPECTION
receipt Is acknovAodged In space provided.
(425)
OFFICIALS SIGNATURE A
N. So
771---46220
46
BY
EXT 1 33
ATTENTION
IQ "Kit AWFUL TO USE OR OCCUPY A Al Ill niMr.' OR STRUCTURE UNTII
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
09/03 PRESS HARD -YOU ARE MAKING 4 CO
ORIGINAL - FILE YELLOW INSPECTC
PINK -OWNER GOLD -ASSESSOR