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DATE RECEIVED
I FPERMIT EXPIRES
USE PERMIT
CITY OF EDMONDS ZONE NUMBER.,
JOB SUITEIAPT#
CONSTRUCTION PERMIT APPLICATION ADDRES,!�)/,�/Z .10 1 /,b /
OWNER NAMEMA ME OF BUSINES S /.:�Z , 67,,_2 J._ ",� 6/ /1 —
PLAT NAMEISUBDIVISION NO LOT NO, LID NO.
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LU MAILING ADDRESS LID FEE S
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3. 21 xj PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Required C3
0 Street Use Permit Rflq'd
EXISTING — PROPOSED inspection Auquiled
ZIP TELEPHONE Sidowfilk Required E3
REQUIRED DEDICATION— FT Undirfground
Wiring required
NAME METER SIZE LI NO. OF FIXTURES PRV REQUIRED
YES 0 NO E3
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OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE 5
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CITY ZIP TELEPHONE
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NAME CBL is StvAe J�4 Industries
,�t_c V"I,1 ENGINEEF DATE- -8
ADDRESS
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FIRE REVIEWED BY DATE
CITY ZIP TELEPHONE
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U - elk"! I I 1 13 ej VARIANCE OR CU SHORELINE OR AD1111 INSPECTION BOND
STATE LICENSE NUMBER EXPIRATION DATE �ECKE 5 BY REO'D POSTED
S (.4 rt) DA f 91 -1 0 J5� SEPA REVIEW SIGN AREA CIYES ONO IS HEIGHT
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PROPER ACCOUNT PARCEL NO. COMPLETE , EXEMPT ALLOWED PROPOSED ALLOWED , PROPOSED
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LOT COVERAGE REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (Fr.)
NEW RESIDENTIAL PLUM13ING / MECH ALLOWED PROPOSED
FRONT SIDE REAR FRONT LJRSIDE REAR
COMPLIANCE OR z
ADDITION COMMERCIAL E
CHANGE OF USE z
PARKING LOT AREA PLANNING REVIEWED BY DATE
REMODEL MULTIFAMILY SIGN ROVIDED
GRADING FENCE
REPAIR CYDS X REMARKS
OTHER
DEMOLISH TANK F-1
GARAGE RETAINING WALL FIRE SPRINKLER
z CARPORT ROCKERY FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
CHECKED BY ...ITYP.9 OF�CONSTRUCTION E OCCUPANT
TvvoqAT /91-9 )7��q '7 GROUP
W NUMBER NUMBER OF CRITICAL
0 OF DWELLING AREAS SPECIAL INSPECTION AREA OCCUPANT
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DESCRIBE WORK TO BE DONE
REMARKS
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PROGRESS INSPECTIONS PER UBC 1108/171NAL INSPECTION REO'D 5
wk"q -Tn ru P- � W .00 P—; 01 su, pc,4.c,� r,;
GAS PIPF TEST MUST BE
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INSPECTOR
VALUATION AFFIDAVITS SHALL NOT
BE ACCEPTED
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W 1&Z2,7r4r�.. Isir Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE % Building Permit city Surcharge
ECK NO: VESTED DATE Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
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: ISO DAYS
EL PERMIT LIMIT'. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
u) Fire Review Plan Chk. Deposit
U) 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
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 it
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ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRFCTtY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
In Landscapeinsp. Total Amt. Due
j DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
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 APPLICATION APPROVAL
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 Building Official or his/tier Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S C5k!Rf�NSATION INSURANCE AND RCW 18.27.
1. �:FiCIALS !�G ATURE DATE
SIGNATUR (OWNER R AGENT) DATE SIGNED (425)
w,—MSED 13Y
771-0220
ATTENTION E)ff 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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1653 E.MAIN STREET
ROCHESTER, NY 14609
TEL C716) 482-0300
FPX (716) 288-5989
Precision 1rA4GE Products & Services
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CERTIFICATE OF
AUTHENTICITY
1, the undersigned, an employee of Micro Com Systems
Ltd., do certify that the documents described on the
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auidesheet taroret are beina filmed in accoi
the Washington State Standards for the production and.
... -nicrofili-n. I also certify that the records
use of i
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copies of the originals. However, no judgement is made
-ne of microfilming as to the validity, accuracy
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61n DAY OF
FILMED THIS
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PRINTED NAME:
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