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PERMIT EXPIRES
PERMIT
CITY OF EDMONDS
NUMBER
JOB SUITE/APT#
CONSTRUCTION PERMIT APPLICATION
ADDRESS
OWNER NAMEINAME OF BUSINES S
FLAT NAME/SUBDIVISION NO,
LOT NO.
LID NO.
LID FEE S
51 fr\ +-DON AJA LA-kyri
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MAILING ADDRESS
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCPApprooed 0
RW Permit Required E3
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36,28' A�"')d A_ 5&0
0
019-11-
EXISTING PROPOSED
Street Use Permit Required E3
inspection Required C3
E3
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CITY ZIP
TELEPHONE
DMOA).O 0-/1 C�6 jLJ-2-5
- -771 !�03 �3
REQUIRED DEDICATION ___ FT
Sidewalk Required
Underground
W.r.n a required C3
NAME
NiETER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
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ADDRESS
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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CITY ZIP
TELEPHONE
NAME
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PURSUANT TO UPC 605.2
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EN INEERINGREVIE%%OY" "�N Lj�&%T
ALL HE INSTALLED ON THE
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ADDRESS
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FIRE REVIEWED BY DATE
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CITY ZIP
9 LyxA),
TELEPHONE
14 2�5-77f564bq
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VARIANCE OR CU
SHORELINE OR ADB
INSPECTION
REQ'D
10YES
SEPA
COMPLETED EXEMPT
STATE LICENSE NUMBER EXPIRATION DATE
CHECKED By
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13NO
CA$1
ZONE
SIGN AREA
HEIGHT
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PROPERTY TAX ACCOUNT PARCEL NO. r
rc
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WAIVERE3
ALLOWED PROPOSED
ALLOYIED PROPOSED
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56, 12 cc
STUDY 13
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NEW RESIDENTIAL PLUMBING MECH
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (FT.)
FRONT SIDE REAR
PROPOSED SETBACKS (FT.)
FRONT L/R SIDE REAR
ADDITION COMMERCIAL COMPLIANCE OR
OF USE
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EMIXED USE CHANGE
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PARKING
LOTAREA
PLANNING REVIEWED 13Y DATE
REMODEL MULTIFAMILY SIGN
REO'D PROVIDED
GRADING FENCE
REPAIR 0 CYOS X FT.)
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REMARKS
DEMOLISH 0 TANK OTHER
E]GARAGE RETAINING WALL FIRE SPRINKLER
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CARPORT ROCKERY FIREALARM
(TYPE OF USE, BUSINE$S'gR ACTIVITY) EXPLAIN:
TYP STRUZCI N
CODE.
OCCUPANT-17
GROUP
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NUMBER
OF
NUMBER617'
DWELLING
ePECIZN�PkTION
CONI�ULTANT
OCCUPANT
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STORIES
UNITS
REQUIRED 13YES
LOAD
DESCRIBE WORK TO BE DONE
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REMARKS
GEOTECASWO.tOrp XXU'"014 "CLIM'g
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Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOI!JRCE —'f
LOTSLOPE%
VESTED DATE
I Building Permit
City Surcharge
/,05
PLAN CHECK NO:
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
Grading
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION *ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: SEE ECDC 19.00,005(A)(5)
Engr. Inspection
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PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATIO14
U) 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
LU IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
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2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
0: OR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
4 ALL CLAIMS F
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
a IFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscapeinsp. Total Amt. Due
DEEMED TO MOD
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0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.,
LReceipt
Recording Fee #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APP I ATION 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 his1her Deputy� and Foes are paid, and
AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
TION:
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION I receipt is acknowledged in space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27. SIGNATURE DATE
�F!tIALS
�IqAyOE(oWNERO,g'�AbENT) DATESIGNED
sl �E(OWNERO �'G�NT)-,`. (425)
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ATTEWION EXT. 1333
IT Iq UNI AWFUL 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. UBC109 / IBC110 / IRC110. PINK -OWNER GOLD ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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