20050004.pdf,e! I I PERMIT EXPIRES OLE ;I
US PERMIT ;
CITY OF EDMONDS ZONE Ci C NUMBER
CONSTRUCTION PERMIT APPLICATION A DRESS
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OWNER NAME NAME OF OU NESS
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
MAILING ADDRESS LID FEE $
_ n TESCP Approved
` PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Required o
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,J I 1r Street Use Permit Roq'd O
CITY ZIP TELEPHONE EXISTING PROPOSED Inspection Sidewalk Required d O
At
r' REQUIRED DEDICATION Fir wiring O
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES ❑ NO ❑
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ADDRESS REMARKS i
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE Z
CITY ZIP TELEPHONE
NAME (, D � .:, CBL #
C* (� ENGINEERING REVIEWED BY DATE
ADDRESS
FIRE REVIEWED BY DATE WW
CITY 1 `1 ZIP TELEPHONE 12
VARIANCE OR CU SHORELINE OR ADB# INSPECTION BOND
(SST E LICENSE NUMBER�J� EXPIRATION DATE CHECKED BY REO'D POSTED
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OYES ONO g
SEPA REVIEW SIGN AREA HEIGHT
PROPERTY TAX ACCOUNT PARCEL NO. COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED
6 4: Q 1 Q I Cl EXP
❑
Pt"M�G MEC NEW 1:1RESIDENTIAL LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
XALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
COMPLIANCE OR
❑ ADDITION ❑ COMMERCIAL ❑ CHANGE OF USE x
PARKING LOT AREA PLANNING REVIEWED BY DATE g
❑ REMODEL MULTIFAMILY ❑ SIGN REO'D PROVIDED
❑. REPAIR ❑ GRADING CYDS ❑ PENCE X FT) REMARKS
❑ DEMOLISH ❑ TANK ❑ OTHER
❑ CARPORT ❑ R RAGE RETAINING CKERY WALL FIRE ❑ FIRE ALARM LER
(TYPE OF USE, BU/S)NESS OR ACTIV" EXPLAIN:
CHECKED BY TYPE OFC NSTRU TI N CO OCCUPANT
GROUP
NUMBER NUMBER OF CRITICAL OCCUPANT
OF yJ Lts DOWELLING AREAS SPECIAL INSPECTION JAWA LOAD
STORIES UNITS NUMBER REQUIRED ❑ YES
DESCRIBE WORK TO BE DONE REMARKS
PROGRESS INSPECTIONS PER UBC 108/IBC109/IRC109FlNALINSPECTIONRE01D 9
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VALUATION
Lip (:x�' Description FEETDescriptlon FEE
Plan Check urcharge
HEAT SOURCE GLAZING % LOT SLOPE% Building Permit rcharge
PLAN CHECK ; VESTED DATE Plumbing Base Fee
Mechanical)
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK T
t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC Grading
aDOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
t SEPARATE PERMISSION.
Engr, Review
PERMIT APPLICATION: 180 DAYS
CL 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 Flf@ Review Plan Chk, Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
21111 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 Ins Total Amt. Due
9 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE p p'
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee Rece=jg
I 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 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.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27. OFFICIALS SIGNATURE DATE
SIGNATURE (OW ORS DATE SIG D (425)
f 3 f) " 771-0220 ATS
RE E *SED
ATTENTION EXT 1333 .,
ITIS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE ANDAPPROVALOR A CERTIFICATE OF OCCU- I RI FILE YELLOW- NSPE TOR
PANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110. PINK - IwNER GOLD -ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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