20050012 (2).pdfDATE RECEIVED
PERMIT EXPIRES
CITY OF EDMONDS PERMIT
ZOSNE NUMBER
CONSTRUCTION PERMIT APPLICATION JOB SUITE/APT#
ADDRESS t��/ nj 1 J n / %j�l l
OWNER NAME/NAME OF B,(,1SINESS
Do rr /� ro PLAT NAME/SUBDIVISION NO. LOT 140. LID NO,
W MAILING ADDRESS LID FEE $
_ + TESCP Approved Q
GC PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Required o
l (,�t,.� �- WG Street Use Permit Roq'd Q
CITY ZIP TELEPHONE
EXISTING PROPOSED Inspection Required Q
Sidewalk Required Q
0(��•� �� REQUIRED DEDICATION FT Underground
I I iviong required [3 4A
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED 0
YES ❑ NO ❑ _
W
C ADDRESS REMARKS z
V OWNER/CONTRACTOR RESPONSIBLE FOR EHOSI E Z
CITY ZIP TELEPHONE vent connectors requ►re
lluraling appt;ances pas 2
NAME CBL # h llllheate
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E BY DATE
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FIRE REVIEWED BY DATE W
�P TELEPHONE M
VARIANCE OR CU SHORELINE OR ADB# INSPECTION BOND
STATE LICENSE NUMBER EXPIRATION DATE I REO'D POSTED
L� BE1}� 108 � Qr I ❑YES ❑NO $
%
SEPA REVIEW SIGN AREA HEIGHT
P��RwwO,,P��E``RTY TAX ACCOUNT PARCEL NO. UVJ COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED
l JV EXP
❑ NEW RESIDENTIAL PLUMBING/MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR O
COMPLIANCE OR zrE
❑ ADDITION COMMERCIAL ❑ CHANGE OF USE Z
PARKING LOT AREA PLANNING REVIEWED BY DATE g
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REO'D PROVIDED
❑ REPAIR ❑ GRADING CYDS ❑ FENCE X REMARKS
❑ DEMOLISH ❑ TANK ❑ OTHER
2 ❑GARAGE FIRE
CARPORT ❑ . ROCKERY WALL 13FIRE ALARM SPRINKLER
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
A, FCHECKED BY TYPE O R C I CO E OCCUPANT
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ONUMBER NUMBER OF CRITICAL /N
to OF DWELLING AREAS SPECIAL INSPECTION AREA OCCUPANT
O STORIES UNITS NUMBER REQUIRED LOAD
YES
DESCRIBE WORK TO BE DONE
REMARKS z
PROGRESS INSPECTIONS PER UBC 108/ISC109/IRC109RNALINSPECTIONREO'D 9
(�CX� VALUATION
$
Description FEE Description FEE
Plan Check State Surcharge
HEAT SOU_ RCFj GLAZING % LOT SLOPE % —
/�t,✓! Building Permit City Surcharge
PLAN dHECK NO: VESTED DATE Plumbing Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
i BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
� Engr. Review
W PERMIT APPLICATION: 180 DAYS
o PERMIT LIMIT. 1 YEAR • PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr, Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
y 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS Fire Review Plan Chk. Deposit
ry 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
3 DEEMED TO MODIF/, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape l Amt. Due
Insp. TotaJ
z NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY '
ORDINANCE PROVISION.
Recording Fee Receipt #
1 HEREBY ACKNOWLEDGE THAT 1 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- CALLThis application is riot 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 Foos 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.
0 LS SIS A RE *AT
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G T (OWNERUG' D `TE S (425)
771m0220 RELEASED BY
A ENTION EXT 1333 -
ITIS UNLAWFULTO USE OR OCCUPYA BUILDING OR STRUCTURE UNTILA FINAL
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCU ORIGINAL -FILE YELLOW- INSPECTOR
PANCY HAS BEEN GRANTED. UBC109 / IBC110/ IRC110. PINK -OWNER GOLD -ASSESSOR
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