20050192.pdfCITY OF EDMONDS
PERMIT EXPIRES
USE . PERMIT /J
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CONSTRUCTION PERMIT APPLICATION JOB
ADDRESS SUITEIAPTB
OWNER NAME/NAME OF BUSINESS Z 3 L A4� `
j PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
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G � LID FEE $MAILING ADUSSw
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Pe Approved O
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�} RW Permit Required
L•�- 32 Al L40e'v 5 Street Use Permit Roq'd
CITY /,ZIP TELEPHONE EXISTING PROPOSED Inspection Required
Sidewalk Required Q
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REQUIRED DEDICATION FT wiring required
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NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
�- YES ❑ NO ❑
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ADDRESS REMARKS Z',
x OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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CITY ZIP TELEPHONE
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NAME CBL N e•• / A l I
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FIRE REVIEWED BY DATE W
CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE CHECKE BY VARIANCE OR CU SHORELINE OR ADEN INSPECTION BOND
%� J �O ` O'D POSTED
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SEPA REVIEW SIGN AREA HEIGHT
PROPERTY fAX ACCOUNT P�EL� � � XOMPLETE EXEMPZ ALLOWED PROPOSED ALLOWED 'PARC POSED
NEW ❑ RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SIDE REAR 117
❑ADDITION Q�OMMERCIAL COMPLIANCE OR
❑ CHANGE OF USE 1 "�O r l � f p t ,S i > _
PARKING LOT AREA PLANNING REVIEWED BY, DATE g
❑ REMODEL ❑ MULTIFAMILY �,�SIGN REQ 'D � PROVIDED ` T �n
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GRADING FENCE
❑ REPAIR ❑ CYDS . ( X FT) REMARK A
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❑ DEMOLISH 13 TANK ❑ , ; ;GARAGE RETAININGn
❑ CARPORT ❑ R OC WALL ❑ FIRE ALARM LER )) ^ L l
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FIRE
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(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
m G4r, /C CHECKED BY PE OF GONSTRUCTIO CODE OCCUPANT
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NUMBER NUMBER OF CRITICAL
o Qp DWELLING AREAS •— % SPECIAL INSPEr.TION I AREA OCCUPANT
O STORIES UNITS NUMBER �-7 REQUIRED YES LOAD
DESCRIBE WORK TO BE DONE
REMARKS i
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D 9
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escription FEE 7Description FEE
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HEAT SOURCE GLAZING % LOT SLOPE %
City Surcharge
PLAN CHECK NO: VESTED DATE Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.'
t Engr, Review
PERMIT APPLICATION: 180 DAYS
a PERMIT LIMIT. 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
2 '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 HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt k 7
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE Landscape Insp, Total Amt. Due
9 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
Y NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee Receipt N
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- CALLThis application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, No PERSON WILL BE EMPLOYED Building 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 COMPENSATI SU WE AND W 18.27.
FFILAIS SIGNAT E DATA
SIGNATURE(OWNER DAT/SNED `4251i 6S 771=0220 R ED 6ATE
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 CERTIFI- ORIGINAL - FILE YELLOW -INSP TO
CATE OF OCCUPANCY HAS BEEN GRANTED, UBC SECTION 109 PINK -°GREEN -'ACCOUNT ASSESSOR
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PERMIT #2C�C2�L�,��6 ADB# DATE INSPECTEDm Z
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DESCRIPTION OF WORK TO BE INSPECTED y z
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A field inspection-: was conducted to determine compliance with -approved plans. Final approval C/)denotes that there are no objections from the above signed Department to the release of D
PERFORMANCE BONDS and the granting of
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GRANT FINAL PROJECT' APPROVAL 9 Ch
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GRANT PROJECT APPROVAL WITH CONDITIONS NOTED Z
❑ Copy of CONDITIONS given to owner/contractor by inspectorCD
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES M
. C� Copy of CORRECTION NOTICE given to by inpector '
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
d:temp:bldg:forms: ocaprvl 3/25/04
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