20050058.pdfDATE RECEIVED
' PERMIT EXPIRES
CITY OF EDMONDS NUM ER c5z/IT 1 V 1
CONSTRUCTION PERMIT APPLICATION JOB aEIAPT#
ADDRESS OWN R NAMEINAME OF Bl{ SS /
� %�/ �`,L��. y . r I / PLAT NAMEISUBDIVISION NO LOT NO. LID NO,
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MAILING ADDRESS ` �r , {/l�Q ) %�/� TC D P tip wea ❑
3 I /� �� �� V `� �V '✓ i PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
p [ V RW ParnelermitRequired ❑-
Streol Use Perms Required ❑
/CIIITTTY/. - ZIP TELEPHONE EXISTING
EXISTING PROPOSED _ inspection Required ❑
r) Sidewalk Required [3 -
REQUIRED DEDICATION FT Underground ❑
Wiring required ❑
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES 17 NOM 2
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ADDRESS REMARKS W
u OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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CITY ZIP TELEPHONE
NAME � Cts WF� C��✓>' C Lp
'W\eUENGINEERING REVIEWED BY DATE
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O FIRE REVIEWED BY DATE
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STATE LICENSE NUMBER EXPIRAEX61
TE C CKED B VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
- J T REQ'D COMPLETED EXEMPT
%
/ l v� / CI YES 0 NO
CAN ZONE SIGN AREA HEIGHT
Q PROPERTY TAX ACCOUNT PARCEL NO.
V, ''') WAIVER O ALLOWED PROPOSED ALLOWED PROPOSED
�O 1 �C_JC./��/ STUDY O
❑ NEW RESIDENTIAL 1X1 PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT.)
l ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR O
❑ COMMERCIAL COMPLIANCE OR Z
❑ ADDITION ❑ CHANGE OF USE Z
❑ MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g
REMODEL ❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED
❑ REPAIR 11 GRADING CYOS ❑ (ENCS X FT.) REMARKS
❑ DEMOLISH ❑ TANK ❑ OTHER
Z ❑GARAGE RETAINING FIRE
CARPORT 13ROCKERY WALL ❑ FIRE ALARM SPRINKLER
a(TYPE OF USE, BUSINE S OR ACTIVITY) EXPLAIN:
TY O aCN T U ON DE GROUPANT
U
w NUMBER NUMBER OF
o OF�- . / DWELLING PECIAL INSPECTION . CONSULTANT OCCUPANT
M STO UNITS REQUIRED DYES - LOAD
DESCRIBE WORK TO BE 0014E
REMARKS i
0
GEOTECH REPORT
BY: m
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BY:
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00(-' Description FEE Description FEE
Plan Check State Surcharge
HE spUR LOT SLOPE% VESTED DATE
L Building Permit City Surcharge
PLA CHECK NO: Plumbing Base Fee
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC Gradin
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE g
SEPARATE PERMISSION,
Engr. Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
I a PERMIT LIMIT: SEE ECDC 19.00,005(A)(6). Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
U) , *APPLICANT* ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire RBVIeW 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 --
G DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee Receipt # '
I 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 This application is not a permit until signed by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL Building Official or his/her Deputy: and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OFP WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27, 0 ALS SIGIjATVRE 6 DA '[
LA
(OWNER AG NT): DA IGNED (425)
771m0220 L A Y DAT
ATION EXT 1333
IT IS UNLAWFUL TO USE OR OCC PY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL • FILE YELLOW • INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 / IBC110 I IRC110. PINK -OWNER GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4. COPIES
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