20040785.pdfj DATE RECEIVED
C - PERMIT EXPIRES
CITY OF EDMONDS ZONE NUMBi R /V IF 2
CONSTRUCTION PERMIT APPLICATION J0° gel
Sl11TE/APT"
ADDRESS6OW ER NAME/NAME OF BUSINESS ( /
1(L Ip EW C, PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
•. LID FEE S
MAILING ADDRESS h, %� TESCP Approved 13
�'Y .5),///I //T /T PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Pormlt Required 0
*7 v19 1 ( V C—� Street Use Pornril Req'd E3
CITY EXISTING Inspection Required
ZIP TELEPHONE PROPOSED
.• e O 7!5 " ! d � � / Al 3 Wiring Required 0
REQUIRED DEDICATION FT Underground
Wiring requited
quired E3
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES ❑ NO ❑ _
W
W
ADDRESS REMARKS i
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
CITY ZIP TELEPHONE
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RESENT
NAME , n T� ! CCBL # " E t 1
IrENGINEl cI0&1 I G R All
IEWEb DATE
ADDRE
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FIRE REVIEWED BY DATE w �
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VARIANCE OR CU SHORELINE OR ADB# INSPECTION BOND
STATE LICENSE NUMBER EXPIRATION DATE CHECK BY
F1REO'D POSTED
coGcl 6frA4 Lo L4O .!r ❑YES ❑NO 5 I
SEPA REVIEW SIGN AREA HEIGHT �
PROP 7 TAX ACCOUNT PARCEL O. COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED
2 EXP 1
1:1 NEW RESIDENTIAL PLUMBING MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
❑ / ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SIDE REAR i
COMPLIANCE OR Z
❑ ADDITION ❑ COMMERCIAL ❑ CHANGE OF USE2
PARKING LOT AREA PLANNING REVIEWED BY DATE g
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN. REO'D PROVIDED
❑ REPAIR ❑ GRADING PENCE
CYDS ❑ X tREMARKS
❑ DEMOLISH �i'ANKGARAGE OTHER
❑ CARPORT ❑ ROCKIERY NING WALL ❑ FIRE ALARM FIRE LER
(TYPE OF`USE, BUSINESS OR ACTN XPLAIN:
n / r/ % BY ITYPE TpUCTION COD OCCUPANT
fit!/ V a..� / GROUP
NUMBER NUMBER OF CRITICA4, (/
OF DWELLING AREAS ' f / NSPECTION AREA OCCUPANT
STORIES UNITS NUMBER ❑ LOAD
YES
DESCRIBE WORK TO BE DONE
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PROGRESSINSPECTIONS PER Uf3C10d/1130109/IRC109FlNALINSPECTION REO'D 9
b OPP 9 N `
/V VALUATION I
ry H �� C $
Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %
Building Permit City Surcharge S
PLAN CHECK NO: VESTED DATE Plumbing Base Fee
Mechanical
THIS PERMIT AUTHORIZES 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, MARQUEES, ETC.) WILL REQUIRE g.
SEPARATE PERMISSION,
Engr. Review
PERMIT APPLICATION: 180 DAYS
d PERMIT LIMIT. 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr, Inspection
SEE BACK OF PINI: PERMIT FOR MORE INFORMATION
N •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 t
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE . Landscape Insp. Total Amt, Due
01 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 CITY AND STATE LAWS REGULATING CONSTRUC-(,•ALL This application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED Building 011icial or his/her Deputy: and Foes aro 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 COMPENSATION INSURANCE AND RCW 18.27.
OFFI I I IGNATURE DATE
SIGNAT (OWN OR E DATE SIG/ Dd L (425)Lj I r l Lk / % /J l^
` o 771=0220 RE SED BY DAT LL
ATfENTIOV EXT 1333
IT IS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE AND APPROVALOR A CERTIFICATE OF OCCU- ORIGINAL - FILE YELLOW - INSPECTOR
PANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110. PINK - OWNER GOLD - ASSESSOR
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