20040963.pdft
DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
QWNEER NAME/NAME OF BUSINESS
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MAILING ADDRESS -
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CITY ZIP TELEPHONE
NAME
ADDRESS
CITY ZIP ITELEPHONE
NAME
ADDRESS
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PLAT NAME/SUBDIVISION NO.
IPERMIT EXPIRES-��
PERMIT
NUMBER
SUITE/Al"Tk
/!. At
LOT N®� LID NO. �_■
LID FEE S
TESCP Approved
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Required
Street use Permit Roq'd
inspeted
EXISTING PROPOSED Sidewalk
Sidewalk Required
REQUIRED DEDICATION Fr Underground
Winng required
METER SIZE I LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES ❑ NO ❑
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ENGINEERING REVIEWED BY
117AC4
FIRE REVI -WED BY DATE
CITY ZIP TELEPHONE `
STATE LICENSE NUMBER
DATE I CHECKED BY
PROPERTY TAX ACQOUNT PARCEL
�❑ NEW `T RESIDENTIAL C/ PLUMBING I MEN CH.
COMPLIANCE OR
❑ ADDITION ❑ COMMERCIAL ❑ CHANGE OF USE
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN
❑ REPAIR ❑ GRADING ❑ FENCE X Fr)CYDS
OTHER
❑ DEMOLISH ❑ TANK ❑
❑GARAGE RETAINING WALL FIRE SPRINKLER
CARPORT ❑ ROCKERY ❑ FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY)`EXP IN: r _
NUMBER NUMBER OF CRITICAL
OF DWELLING I AREAS
STORIES UNITS NUMBER
DESCRIBE WORK TO BE DONE
111010
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..HEAT SOURCE
PLAN CHECK NO:
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VESTED DATE
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
F DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
J SEPARATE PERMISSION.
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= PERMIT APPLICATION: 100 DAYS
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CIL PERMIT LIMIT: 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
N 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
n IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
M EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
¢ ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
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FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF THIS PERMIT SHALL NOT BE
S DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
O NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.•
x
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
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKME 'S COMPENS ON INSURANCE AND RCW 18.27.
SIGNAT (OWNER Ob AGENTV/ DATE SIGNED
OCCUPANT
GROUP
SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED LOAD
❑ YES
REMARKS
PROGRESS INSPECTIONS PER UBC 108/IBC109/IRC109 FINAL INSPECTION REQ'D 9
VARIANCE OR CU
SEPA REVIEW
COMPLETE EXEMPT
EXP
LOT COVERAGE
ALLOWED PROPOSED
SHORELINE OR ADB# INSPECTION UUNU
REO'D POSTED
❑YES ONO S
SIGN AREA HEIGHT
ALLOWED PROPOSED ALLOWED PROPOSED
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REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (FT.)
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PARKING LOT AREA PLANNING REVIEWED BY DATE a
REO'D I PROVIDED I
REMARKS
CHECKED BY ITYPE
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VALUATION
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Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
FEE Description FEE
State Surcharge
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City Surcharge AS
Base Fee
Plan Chk. Deposit
Receipt k
Total Amt. Due
Receipt N Z�s�
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or his/her Deputy; and Fees are paid, and
receipt is acknowledged in space provided.
=FIALS SIGf•}PTURE DATE
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EASED BY DATE
ATTENTION' v E)T 1333
IT IS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE AN D AP P R OVAL OR A CERTI FI CATE OF OCCU• ORIGINAL • FILE YELLOW • INSPECTOR
PANCY HAS BEEN GRANTED. UBC 109 / IBC110 / IRC110. PINK -OWNER GOLD -ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
Fire Review
Fire Inspection
Landscape Insp.
Recording Fee
CALL
FOR INSPECTION
(425)
771-0220
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I
I I DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
CL/ NER�NAME/NAME 1OF BUSINESS
fi
MAILING ADDRESS
CITY ZIP TELEPHONE
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"i iff;
ADDRESS
CITY ZIP I TELEPHONE
NAME CBL N
ADDRESS
CITY ZIP I TELEPHONE
STATE LICENSE NUMBER EXPIRATION DATE I CHECKED BY
PROPERTY TAX AC 0UNT PARCEL NO.
❑ •0•RESIDENTIAL n`. UMBING / MECH.
CH,�
NEW 1❑
❑
ADDITIONCOMPLIANCE OR
COMMERCIAL ❑ ❑ CHANGE OF USE
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN
GRADING FENCE
❑ REPAIR ❑ ; : ❑ ( X FT) RE
1t NOTHER
❑ DEMOLISH ❑ TANK
GARAGE RETAININ&VfALL 1 PRE SPRINKLER
z ❑ CARPORT ❑ ROCKERY' _ ❑ FIRE ALARM
(TYPE O USE, BUSINESS OR ACTIVITY)'EXPI AIN:
NUMBER / NUMBER OF CRITICAL
OF !_ DWELLING AREAS
STORIES J UNITS NUMBER
PERMIT EXPIRES
USIE PERMIT
ZONE NUMBER
JOB
ADDRESS
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PLAT NAME/SUBDIVISION NO.
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LOT NO. LID NO.
LID FEE $
TESCP Approved ❑
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW Permit Required ❑
Street Use Ponnit Roq'd ❑
EXISTING PROPOSED
Inspection Ronuired ❑
Sidewalk Required ❑
REQUIRED DEDICATION FT
Underground
Wiring required ❑
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
0
YES ❑ NO ❑
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REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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ENGINEERING REVIEWED BY
DATE
FIRE REVIEWED BY DATE w
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VARIANCE OR CU SHORELINE OR ADBN INSPECTION BOND
REQ'D POSTED
OYES ❑NO S
I DESCRIBE WORK TO BE DONE
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HEAT SOURCE
PLAN CHECK NO:
k Ifi r,6e
SEPA REVIEW
SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
EXP
LOT COVERAGE
REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT L/R SIDE REAR
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PARKING
LOT AREA
PLANNING REVIEWED BY DATE
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REO'D I PROVIDED
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GROUP
SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED LOAD
❑ YES
REMARKS
r,
PROGRESS INSPECTIONS PER LlBC108/IBC109/IRC109 FINALINSPECTION REQ'D 9PLO
ED BY • I TYPE
V1�",C�/I I. V4VALUATION
jBuilding
on FEE Description
.r
State Surcharge
L,OT MOPE7
mit j� City SurchargeVESTEDDATE Base Fee e0f, ;
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
GLAZING %
Fit UUNt UN YIIIVAIC YNUYCHI T UNLT. ANT VUNAIr,\J 15mrx vn rn� v,.u". Grading
E DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
f Engr.. Review
u PERMIT APPLICATION: 100 DAYS
L PERMIT LIMIT. 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr. `Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
FEE
*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
f 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 Landscape Insp. Total Amt. Due r • b
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
O NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.' ] c r^
= Recording Fee Receipt N
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 THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED 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 INSPECTION receipt is acknowledged in space provided.
WORKMEM'S COMPENSATION INSURANCE AND RCW 18.27. C OFFICIALS SIGNATURE DATE
r DATE SIGNED /(425)
SIGNATURk (OWNER O AGENT)/ i:'
P�'} nn
✓ +rl:' i ,° (" .i r� t, f�+4f E �,.._;.' A t � f (j� % ,� L., '` 771 w0220 RELEASED BY DATE
ATTENTION/ ��' ' EXT 1333 ;,a
IT IS UNLAWFULTO USE OR OCCUPYA BUILDING OR STRUCTURE UNTILAFINAL r -
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCU- ORIGINAL. FILE YELLOW • INSPECTOR
PANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110. PINK -OWNER COLD -ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES