20040915.pdfDATE RECEIVED I
PERMIT EXPIRES
USIV PERMIT
CITY OF EDMONDS ZONE NUMBER
CONSTRUCTION PERMIT APPLICATION A D SUITE/APTM
ADDRESS p
OW R NAME AME OF BUS ESS,Ile �I l
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PLAT NAME/SUBDIVISION NO. LOT NO. LID N0.
AILI)i�pABSS LID FEE $
O '((// II// /" i Ll -t q )�[% e� PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP AW PP mit Req d p
(.� ' 1 V L% ✓ ���/// RYI Permit Requlrotl
Street Use Permit Roq'd
ITY ZIP TELEPHONE EXISTING PROPOSED Inspection Required
_ 77� - Sidewalk Required
C/V�f REQUIRED DEDICATION FT Wiring egnd
- Wiring required Q
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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YES ❑ NO 13_
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C ADDRESS REMARKS i
V OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE S
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CITY ZIP TELEPHONE W SSP
NAME CBL #
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FIRE REVIEWED BY DATE
CITY ZIP TELEPHONE W
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VARIANCE OR CU SHORELINE OR ADB# INSPECTION BOND
STATE LIC SE NUMBER T EXPIRATION DATE I RCKE2Y I REO'D POSTED
bl �� ^J �5. ❑YES ONO S
SEPA REVIEW SIGN AREA HEIGHT
PROPERTY TAX ACMP2!EM COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED.
(7 %
C r EXP
❑ LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
NEW 1:1 RESIDENTIAL LUMBING/MECH
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR Z
COMPLIANCE OR
❑ ADDITION ❑ COMMERCIAL ❑ CHANGE OF USE _
PARKING LOT AREA PLANNING REVIEWED BY DATE g
❑ REMODEL MULTIFAMILY ❑ SIGN REO'D PROVIDED
❑ REPAIR ❑ GRADING ❑ PENCE
CYDS X FT)REMARKS
E]DEMOLISH ❑ TANK ❑ OTHER
_ ❑GARAGE RETAFIRE
CARPORT ❑ FIOCKIERY NING WALL ❑ FIRE ALARM SPRINKLER
O (TYPE OF USE; BU ESS OR N EXPLAIN:
CHECKED BY TYP C I CQ8r/) OCCUPANT
Q GROUP
ONUMBER NUMBER OF CRITICAL
OF DWELLING / AREAS SPECIAL INSPECTI N AREA OCCUPANT
O STORIES UNITS '- , NUMBERA& REQUIRED [ LOAD
YES
DESCRIBE WORK TO BE DONE
REMARKS 2
PROGRESS INSPECTIONS PER UBC 108/ IBC109/ IRC109 FINAL INSPECTION REO'D 9
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5 Description FEE Description FEE
2LPlan Check State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %-�*
Building Permit City Surcharge
PLAN CHECK NO: p VESTED DATE Plumbing Base Fee
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
7 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION,
Engr. Review
w PERMIT APPLICATION: 180 DAYS
L 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
XEDMONDS, 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
�] DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE p p'
s NOR LIMIT IN ANY WAY THE CITY'S 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 1 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 EMPLOYED This
Official or his/her 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 COMPENSATIO a NCE AND RCW 18.27.
OFFICIALS SIGNATURE DATE
SIGN URE O A ENT) DATE SIGNED (425) C r)4
�,� �/(OWNER, 771-0220 rV�..%n �il�-_ Z c'
REL ED BY DATE
ATTENTION EXT 1333
ITIS UNLAWFULTO USE OR OCCUPYA BUILDING OR STRUCTURE UNTILA FINAL l `
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCU- ORIGINAL. FILE YELLOW - INS CTO
PANCY HAS BEEN GRANTED, UBC109 / IBC110 / IRC110, PINK -OWNER GOLD -ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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