20040130.pdfI
DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINES�,_ _ _ _ I `�> - I I
ass
USE
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JOB
ADDRESS
7
PERMIT EXPIRES
PERMIT
NUMBER
SUITE/APT#
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PLAT N 4E/SUBDIVISION NO. LOT NO. LID NO.
MAILING ADDRESS
I
LID FEE S
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Permit Required
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Street Use Permit R00
CITY T
EXISTING —
PROPOSED
inspection Required
Sidewalk Required
REQUIRED DEDICATION— Fr
Underground
WA
Widng required
NAME
METER SIZE
LINE SIZE
NO. OF FIXTURES
RV REQUIRED
Arc-L
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I YEPs E3 NO 13
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ADDROSS'
REMARKS
6-
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROWDRAINAGE
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CITY ZIP TELEPHONE
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NAME CBLN
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ENGINEERING REVIEWED
BY DATE
0 ADDRESS
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FIRE REVIEWED BY
DATE
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CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE C VARIANCE OR CU SHORELINE OR ADB# INSPECTION IS BOND
JCKED BY REO'D POSTED
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2
1.
OYES 13NO
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SEPA REVIEW
SIGN AREA," HEIGHT
PROPERTY TAX ACCOUNT PARCEL- NO.
COMPLETE EXEMPT ALLOWED PROPOSED `ALLOWED PROPOSED
7 _0q- 0 C>
-7
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EXP
NEW RESIDENTIAL LUMBING I MECH
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LOT COVERAGE REQUIRED SETBACKS (FT.)' ' PROPOSED SETBACKS (FF.)
ALLOWED PROPOSED
FRONT SIDE REAR FRO LJRSIDE REAR
10 COMPLIANCE OR
ADDITION �OMMERCLAL
13 CHANGE OF USE
F
REMODEL 0 SIGN
PARKING
RECID I PROVIDED
LOT AREA PLANNING REVIEW901 I§* DATE
GRADING FENCE
REPAIR 13 13
CYDS ( X FT)
REMARKS
13 DEMOLISH 0 TANK OTHER
GARAGE -1 REIAINING WALL F RE SPRINKLER
11
CARPORT ROCKERY FIRE ALARM
(TYPE OF USE, SINES OR ACTIVITY)i EXPLAIN
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CHECKED BY
T C 0 CODE OCCUPANT
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]TYPE
GROUP
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NUMBER NUMBER OF CRITICAL
OF DWELUNG AREAS
SPECIAL INSPECTION
OCCUPANT
NITS NUMBE
STORIES U R op
REQUIRED YE
13 s
JAREA
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS
PER U13C 1081FINAL INSPECTION REG'D
GAS PIPE TEST MUST BE
CID
Qll;ilg�F 4.,r eaz+ 9 be A,"& %,,r-
OBSERVED BY CITY INSPECTOR
%
VALUATION
AFFIDAVITS SHALL NOT
$
BE ACCEPTED
Description
fEE Description FEE
Plan Check
State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %
Building Permit'
City Surcharge
PLAN CHECK NO: VESTED DATE
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORMES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
I= BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBILIC
2
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPUCATION: ISO DAYS
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
Fire Inspection
Receipt #
IALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF THIS PERMIT SHALL NOT BE
9 REQUIREMENT
Landscape Insp.
Total Amt. Due
DEEMED TO MODIFY, WAIVE OR REDUCE ANY OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
x
Recording Fee
Receipt #
1 HERE13Y 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 application Is not a permit until signed by the
TION: AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE I 'APLOYED
Building Official or his/her Deputy: and Fees are paid. and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON IiLb,; ING TO
FOR INSPECTIO receipt Is acknowledged In space provided.
OMPENSATION INSURANCE AND RCW 18.27.
SIGNATURE (OWNER AGENT) DATE SIGN 0
1A9
FI S SIGNATOE DATE/
tr __D /I
1�:, � 6� — YYLL11_4
vjj,� k /0 77%1-022 ASED BY DAftE
ATTENTION EOMXffT 13 3 3
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
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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DATE RECEI
FP ERMIT EXPIRES
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C11Y OF EDMONDS
Z_O�E Z,�7 /10 PERMIT
AV NUMBER
CONSTRUCTION PERMIT APPLICATION
JOB SUITE/APT#
ADDRESS
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OWNER NAMEINAME OF BUSINESS
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PLAT NAME/SUBDIVISION NO.
LOT No'
LID NO.
LID FEE S
;Per.mit'llsq'd
15
MAILING ADDRESS
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING — PROPOSED
REQUIRED DEDICATION— FT
TESCP AP
Rw PerrrAt Required
Street Use
inspection Required
Sidewalk Required
Underground
Wmg required CI
CITY ZIP NE
7 2.2 c15
NAME
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METER SIZE E SIZE NO. OF FIXTURES
1
PRV REQUIRED
YES13 NO 13
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ADDREAS'
C_
REMARKS
WNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
CITY ZIP
TELEPHONE
T_�41you �j il e-, _a0A 0
7 7 3 et) 17
NAME
CBL#
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ENGINEERING REVIEWED BY DATE
ADDRESS
CC
54 A 0
FIRE REVIEWED BY DATE
0
CITY ZIP
- G�_.4 y.. tx.-, j o I
ONE
G "7 Co q`0 C) I
VARIANCE OR CU
SHORELINE OR AOB#
INSPECTION
REO'D
10YEs 13NO Is
BOND
POSTED
STATE LICENSE NUMBER EXPIRATION DATE
aSEPA
D BY
REVIEW
L;UMtLt:1t: t: EMPT
SIGN AREA
ALLOWED PROPOSED
HEIGHT
ALLOWED PROPOSED
PROPERTY -TAX ACCOUNT PARCEL NO.
_0q-7 0
EXP
,
,
NEW RESIDENTIAL LUMBING MECH
.,;,KPCoMPLIANCE OR
ADDITION COMMERCIAL 11 CHANGE OF USE
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (Fr.)
FRONT SIDE REAR
PROPOSED SETBACKS (Fr.)
FRONT L/RSIDE REAR
.
PARKING
REQ`D PROVIDED
I I
LOT AREA _�NNING
REVIEW ED BY DATE
REMODEL
��MULTIFAMILY SIGN
06
L_
[3 GRADING FENCE
REPAIR I CYDS ( _ X_FT)
,
REMARKS
DEMOLISH TANK OTHER
GARAGE RETAININGWALL F RE SPRINKLER
CARPORT ROCKERY F:RE ALARM
(TYPE OF USE. BUSINESS OR ACTIVrM EXPLAIN:
44&�w "C;zic -
CHECKED BY
T UCT'
ITYPE 0 T LICTION,
CCUTE
OCCUPANT
GROUP
NUMBER
OF
STORIES
NUMBER OF
DWELLING
UNITS
C RITICAL
C'
I
AREAS
NUMBER
SPECIAL INSPECTION ?AR
REQUIP
AREA
OCCUPANT
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REI70
OV6.
F"le
G. A E TEST MUST BE
611 [poigr14— LO V�t
n SERVE!
i'� 1 1 L J 1 ^'!� Ir V" r�
VALUATION'
-NSPiCTOR
A E 1 1 S_
1
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Z220
$
F -0 A V -1 S_ H__A_ L L H -0 -1
ACCERIED
Description
FEE
Description
FEE
___7L70NG
Plan Check
State Surcharge
HEAT SOURCE % LOT SLOPE % Building Permit City Surcharge
T
VESTED DATE Plumbing A
PLAN CHECK NO: Base Fee
Mechanical
THIS PERMrr AUTHORIZES ONLY THE WORK NOTED. THIr PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERITV ONLX ANY CONSTRUCTION ON THE PUBLIC
:1 GradIng
DOMAIN (CURBS, SIDEWALKS. DRIVEWAYS. MARQUEES. ETC.) WILL REQUIRE
SEPARATE PERMISSION. Engr. Review
PEIRMITAPPLICATION: 160DAYS
PERMIT UMTP I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT. ON BEHALF QF 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
DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due
NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.' -.01
Recording Fee Receipt #
I 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 APPUCATION APPROVAL
THE OWNER. I AGREE TO COMPLY WITH C17Y AND STATE LAWS REGULATING CONSTRUC This application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED' CALL Building Official or his/her Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTIO receipt 13 acknowledged In space provided.
WORKMENS COMPENSATION INSURANCE AND RCW 18.27.
SIGNATURE (OWNnER��AGENTI) DATE SI �o 142 7
FIrZ SIGNATL#E DATE/
%._5 4W-L4
-_-�
(
ca j
0� 0 771-0227 ItASED BY- DATE
ATTENTION EXT 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
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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