20050147A.pdfDATE RECEIVED
��x/ PERMIT EXPIRESOf
CITY OF EDMONDS NUMBIER �`f �0.'� 1�%��
CONSTRUCTION PERMIT APPLICATION JOB L- _ - �sulTE1apTr:
ADDRESS
OWNER AMMNAME OF BUSINESS /
1 {�� ' PLAT NAMEISUBDIVISION NO. LO N0. LID NO.
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MAILING ADDRESS / LID FEE $TESCPApproved ❑
c PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
� RW PermitRntuvaf [3Street Use Pdmut Requited ❑
CITY ZIP(�'1 TELEP^`sHONE — 1/ ! _ (/ \/ EXISTING _ PROPOSED _ Inspection Required ❑
�G+lf �•lJ (L, ,_ / l'� lr7 .J �r _ Sidewalk aairedRequited ❑
REQUIRED DEDICATION FT Underground ❑
Winn required ❑
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES O N013 z
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ADDRESS REMARKS w
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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ZIP ITELEPHONE
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I ✓A 70A•s �� Lf ENGINEER q r A , ^- / �} /.� [� CAF DATE
ADDRESS I �r" ��L, REMOVAL, OR CAF
CITY ZIP TELEPHONE FIRE REVIEWED BY DATE w
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STATE LICENSE NUMBER EXPIRATION DATE YCH KED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPAi_ REQ'D COMPLETED EXEMPT
`�I /V fV'C� !°� ! C> l t V / `/ r �f OYES i� NO
CA# ggZONE SIGN AREA HEIGHT
PROPE� TAX ACCOUNT PARCEL NO. WAIVER
Y ALLOWED PROPOSED ALLOWED PROPOSED
6 STUDY O
r%LOT COVERAGE REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT.)
❑ NEV RESIDENTIAL ❑ PLUMBING I MEChI ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR 0
❑ COMMERCIAL COMPLIANCE OR z
❑ ADDITION CHANGE OF.USE z
E] MIXED USE PARKING LOTAREA PLANNING REVIEWED BY DATE n
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REO'D PROVIDED
❑ REPAIR ❑ . GRADING CYDS ❑ FENCE
( X FT.) REMARKS
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❑ DEMOLISH TANK ❑ OTHER
❑GARAGE RETAINING WALL FIRE SPRINKLER �T Vol
CARPORT ❑ ROCKERY ❑ FIRE ALARM "/dqSr ✓�- zxe.YV
( OF USE, BUSINESrS OR TIVITY1•EXPLAIN: r^ l
\ /;�� i /l TYPE F C NSTRUCTIONE GOCCUP
R ANT L,
NUMBER 1 NUMBER OF
OF DWELLING / SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES UNITS LOAD
DESCRIBE WORK TO BE DONE REQUIRED YES
REMARKS
GEOTECH REPORT
h BY:
/ •� V r �" STRUCTURAL DESIGN
/ VALUATION
Description FEE Description FEE
Plan Check Slate Surcharge
T
EAT SOURCFj LOT SLOPE% VESTED DATE /
r ! � 1 — Building Permit , �) City Surcharge %
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
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
L 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 Review Plan Chk. Deposit
IN INTEREST, AGREES 1'0 INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
IF EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
i ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY -
= FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE
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 # ! 'r
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. 1 AGREE O COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• CALL Building Official or his/her Deputy: and Fees are paid, and
TION; AND IN DOIN E ORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED receipt is acknowledged in space provided.
IN VIOLATION OF HE LA OR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION
WORKMEN'S CO PENSATI _ IK RANCE AND RCW 18:27.
DATE SIGNED OF � BjSICjNAT E DTE
SIGNAT (OMNERGIEN-r): (425).
y 1
771 -0220 R EA ED BY AT l
ATT ION V EXT. 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A F114AL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL • FILE YELLOW • INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC1091 IBC110 I IRC110, PINK • OWNER GOLD • ASSESSOR
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