20040285.pdfDATE RECEIV D / [
PERMIT EXPIRES
USE PERMIT
CITY OF EDMONDS ZONE �d NUMBER &11' J
CONSTRUCTION PERMIT APPLICATION JOB SUITE/APT#
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OWNER NAME/NAME OF BUSINESS /
Uk Q��L PLAT NAME/SUBDIVISION Nu. Lui rvu. Atli r.v.
w LID FEE $
MAILING ADDRESS TESCP Apprornd O
G PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Required
Amira�• / _ ��• Street Use Permit Roq'd
Inspection Required E3
CITY ZIP I(1�ELEPHONE EXISTING ��— PROPOSED Sidewalk Required O
FUnderground
REQUIRED DEDICATION�
Wiling required O
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES 13NO ❑ W
ADDRESS REMARKS 2
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE (t
CITY ZIP TELEPHONE d�4 4alaeljl'
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NAME CBL#
L ( l �� / %LT ENGINEERING REVIEWED BY DAT
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J*LEPHONE
I FIRE REVIEWED BY DAT wCITY ZIP M
O7 G VARIANCE OR CU SHORELINE OR ADB# INSPECTION BOND
STATE LICENSE NUMBER EXPIRATION DATE CHE KED Y REO'D POSTED
[S' / 12G L /
OYES ONO s
SOPA REVIEW SIGN AREA HEIGHT
PROPERTY TAX ACCOUNT PARCEL NO. COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED
D EXP
❑ NEW ❑ RESIDENTIAL ❑ LOT COVERAGE REQUIRED SETBAC
PLUMBING KS (FT) PROPOSED SETBACKS (FT)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR O
COMPLIANCE OR z
. borr)b5 ❑ COMMERCIAL ❑ CHANGE OF USE z
PARKING LOT AREA PLANNING REVIEWED BY DATE Sa
❑ REMODEL MULTIFAMILY ❑ SIGN REO'D PROVIDED
FENCE
❑ REPAIR �M CYDS ❑ I X FT) REMARKS
1:1DEMOLISH ❑ TANK y.. ❑ OTHER
z 1:1GARAGE RETAFIRE
CARPORT ❑ ROCKIERY NING WALL ❑ FIRE ALARM SPRINKLER
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(TYPE OF USE, BUSINE OR ACTIVITY) EXPLAIN:
�— CHECKED BY TYPE OF CONSTRUCTION ICODE OCCUPANT
GROUP
oNUMBER NUMBER OF. CRITICAL
OFDWELLING I'�/A AREAS SPECIAL INSPECTION JAREA OCCUPANT
STORIES UNITS NUMBER REQUIRED ❑YES LOAD
DESCRIBE WORK TO BE DONE
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REMARKS z
_ PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REGIO 9
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C7>P-s i41 VALUATION
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Description FEE Description FEE
r Plan Check State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE, —�
N ;> � Building Permit City Surcharge 15
PLAN CREC VESTED DATE Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
I_ BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION,
Engr. Review
PERMIT APPLICATION: 180 DAYS
a PERMIT LIMIT. 1 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 %
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 Landsca a Ins Total Amt. Due
9 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE p p
O NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
_ Recording Fee Receipt q 4 zKa
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 CITY AND STATE LAWS REGULATING CONSTRUC- CALL This application is not a permit until signed by the
TION; AND IN DOING THW,(�RV
ORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED Building Official or his/her Deputy: and Fees aro paid, and
IN VIO N OF HEDE OFTHE STATE OF WASHINGTON RELATING TO . FOR INSPECTION receipt is acknowledged in space provided.
WOR EN' COM NSIRANCE AND RCW 18.27.
OF CIL SIGN T RE DATE
SIG ITU(OWIRINI n DATE SIGNED (425)/��/j q/0 41
Y v 7�1 -0220 RELF '=D BY " i DAff
A ENTION EXT 1333 l'jda,
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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 INSP CTOR
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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