20050110 (2).pdfDATE RECEIVED
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L/ PERMIT EXPIRES
CITY OF EDMONDSTNADDRE
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CONSTRUCTION PERMIT APPLICATIOJOBADDRESS /� UIrE/APT#
OWNER NAMEINAME OF BUSINESS �1�r
�- EISUBDIVISION NO. L'O NO. LID NO.
MAILING ADDRESS LID FEE S
�" T /� GHT OF WAY PER OFFICIAL STREET MAP TESCP Approved ❑gel I/ !I �/ r7 �-rwGLSRW Perrnn Required Q
Street Use Permit Requited ❑CITY ZIP TELEPHONE PROPOSED Inspection RequitedISidewalk RequiredC/1tG3 iUC�S �` f� 7� — / D DEDICATION FT underground ❑
Wiring required Q
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES 13 NO O z
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ADDRESS REMARKS W
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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W
CITV 71P I TPI PPW)w: -
NAME CBLt$
ENGINEERING REVIEWED BY DATE
ADDRESS
U ' FIRE REVIEWED BY DATE
CITY ZIP TELEPHONE W
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STAT LICENSE NUMBER EXPIRATION DAT C KED Y VARIANCE OR CU SHORELINE OR ADBN INSPECTION SEPA
REO'D COMPLETED I EXEMPT
/��TC O ✓ / 13 YES 13 NO
PROPERTY TAX ACCOUNT PARCEL NO. CAfi ZONE SIGN AREA HEIGHT
..yyWAIVER .13 ALLOWED PROPOSEDALLOWED PROPOSED
!r 7 &) Z/QC1/7 STUDY O
❑ NEW D9. EESIDENTIAL ❑ PLUMBING I MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
�`'' ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
1:1 COMPLIANCE COMPLIANCE OR z
❑ ADDITION ❑ CHANGE OF USE z
❑. MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE og
REMODEL ❑ . MULTIFAMILY ❑ SIGN REO'D PROVIDED
❑ REPAIR ❑ GRADING CYDS ❑ ENCS X FT.) REMARKS
DEMOLISH ❑ TANK ❑ OTHER
❑ GARAGE CARPORT ❑ ROCKIERY NING WALL ❑ FIRE SPRINKLER LER
(TYPE OF USE, BUSINESS ACTIVITY) EXPLAIN.
/- TY OF CONSTRUCTION CODE OCCUPANT
/) 0GROUP
NUMBER NUMBE OF ` '/
OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES . UNITS LOAD
REQUIRED YES
DESCRIBE WORK TO BE.DONE
/ REMARKS
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GEOTECH REPORT ,
BY: -�
STRUCTURAL DESI N
BY: G/ V
VALUATION
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Description FEE Description FEE
Plan Check Slate Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit ! City Surcharge C�
PLAN CHECK NO: Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
- BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
E DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION.
E Engr. Review
t PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
� PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engf. Inspection
*APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire R@VIEW Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EEDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
z ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE
3j DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due J
D NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
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Recording Fee Receipt #10 2
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 This application is not a permit until signed by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- GALL Building Official or hislhor Deputy: and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED receipt is acknowledged In space provided.
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION -
WORKMEN'S COMP SATION INSURANCE AND RCW 18:27, OFFICIALS IGNATU DATE
SIGNATU NER A�T): DATE SIGNED (425) ''' 1 �,•-
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wor!1K -l/ f— '?~ �v`� 771w0220 RELEASED 6Y DE
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ATTENTION EXT. 1333
IT IS UNLAWFUL TO USE OR OCCUPY 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. UBC1091 IBC110 I IRC110t PINK -OWNER • GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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