20050149.pdfDATE RECEIVEDn ' )
2 PERMIT EXPIRES
PERMIT
CITY OF EDMONDS ZONEa2 NUMBER C� -ci
CONSTRUCTION PERMIT APPLICATION ADDRESS (� ` SUITE/APTM
OWNER NAME/NAME OF BUSINESS
TKeIo /� Cil PLAT NAME/SUBDIVISION NO. L T NO. LID NO.
MAILING ADDRESS 1 LID FEE S
2 j,r TESCP Approved' Q
p �3 (j /J`' 5 Q� + PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Requtrod
/- Street Use Permit Rq'd ��
CITY EXISTING PROPOSED Inspection Roqulrud
ZIP TELEPHONE Sidewalk Hoc
��(�y OZIJ Zs hid.' C7 REQUIRED DEDICATION����rFT wiringr required E3
NAME. /y✓ METEn SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED O
l/� Z
YES 13 NO 13Z
t ADDRESS / REMARKS z
Q'�} ,�;L _fie OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE Z
�[ ( r{Yl W
CITY ZIP TELEPHONE Q 1 Y
NAME CBL N
IA It Pei q!5 0
ENGINEERING REVIEWED BY J 1! DATE
ADDRESS r l l mac, (''o
FIRE REVIEWED BY DATE Lu
TY ZIP } TELEPHONE LL
U �
STATE L ENSE NUMBER (Jr EXPIRATION ATE 0 VARIANCE OR CU SHORELINE OR ADB# INSPECTION BOND
,%� REO' POSTED
OYES NO 5 -----�
SE REVIEW SIGN AREA HEIGHT
PROPERTY TAX ACCOUNT PARCEL NO. COMPLETE E PT ALLOWED PROPOSED ALLOWED PRQP,OSED
3q D7% -Al � �DO EXP 0 C1111�"'
❑ NEW RESIDENTIAL ❑ PLUMBING / h1ECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS )
ALLOWED ROPOSEQD FRONT SIDE REAAR FRONT' U5 SIDE RWCOMPLIANCE OR /O
❑ ADDITION ❑ COMMERCIAL ❑ CHANGE OF USE / V J L bl%4 4. �• / 1 " 7 "5.6" 7 _
PARKING LOT AREA P NNING REVI ED BY DATE g
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN RE41'D PROVIDED no
� ) � J '
GRADING FENCE v]�
❑ REPAIR ❑ CYDS ❑ ( X FT) REMARKS
CARPORT ROCKERYLi FIRE ALARM
(TYPE OF USE, BU"SS SS O AqrlVITY) XPLAIN:
NUMBER NUMBER OFCRITICAL JULT
OF / DWELLING AREAS
�
STORIES ) UNITS d NUMBER
DESCRIBE WORK TO BE DONE
CHECKED BY TYPE OF C NS RUCTION CODE OCCUPANT
GROUP
SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED ❑ YES LOAD
REMARKS t9
PROGRESS INSPECTIONS PER UBC 108/ IBC109/IRC109 FINAL INSPECTION REQ'D 9
Description FEE Description FEE
Plan Check State Surcharge ` C7
HEAT SOURCE GLAZING % LOT SLOPE % ) v
City Surcharge
Building Permit G
VFSTE DAT
PLAN CHECK NO: j(� . � Plumbing ' Base Fee �
v I Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC Grading
3 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
W PERMIT APPLICATION: 180 DAYS
CL PERMIT LIMIT. 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr, Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS Fire Review Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HAnMLESS THE CITY OF
MEDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt # Lig
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE (() D
g DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due -C I t
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee Receipt # (? t
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
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL. This application Is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED This
Official or his/her Deputy: and Fees 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.
FFI LS SIGNAT E
SI �ATU E ' R AGENT) r DATE �IGNED (425) / J (/� I !%/ /�
4,1 ` 771 0220 - - iii(((JJI is ` lY rr.r
/ . ZZ
C�l/:il,�%t✓�' Y =)L' U � FSE B DAT
ATTENTION EXT 1333
IT IS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCU lcwAL •da YELLOW -INS ECTO
PANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110, PINK -OWNER GOLD -ASSESSOR
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