20050200.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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LM MAILING ADDRESS
CITY ZIP TELEPHONE
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NAME
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C ADDRESS
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CITY ZIP TELEPHONE
NAME CBLN
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M ADDRESS
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PERMIT EXPIRES q ih5-
USE PERMIT nn �aG�
ZONE NUMBER 006
JOB SUITE/APT#
ADDRESS
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PLAT NAME/SUBDIVISION NO. VLOT NO, LID NO.
LID FEE $
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP Aw Pe mit Required RW Permit ReQukod
Street Use Permit Roq'd
EXISTING PROPOSED Inspection Required 0
Sidewalk Required Q
REQUIRED DEDICATION- FT Underground
Wiring required E3
METER SIZE LINE SIZE N0. OF FIXTURES PRV REQUIRED O
YES ❑ NO ❑ z
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REMARKS i
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
FIRE MARSHAL
9� FIRE REVIEWED BY S DATE
CITY ZIP Ix
TELEPHONE l9 i -i
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STATE LICENSE NUMBER EXPIRATION DATE C CKED Y VARIANCE OR CU SHORELINE OR AOBN INSPECTION BOND
REQ'D POSTED
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DYES ONO $
SEPA REVIEW SIGN AREA HEIGHT
PROPER T COUNT PARCEL NO. COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED
EXP
❑ NEW RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
COMPLIANCE OR m
❑ ADDITION ❑ COMMERCIAL ❑ CHANGE OF USE Z
PARKING LOT AREA PLANNING REVIEWED BY DATE d
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED
❑ REPAIR ❑ GRADING ❑ FENCE CYDS X FT) REMARKS
❑ DEMOLISH TANK ❑ OTHER
GARAGE RETAFIRE
Z ED CARPORT ❑ R CKIERY NING WALL ❑ FIRE ALARM SPRINKLER
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN: 1
/1; 1 ^�, n� CHECKED BY ITYPIS)C,Oti^TEj ION C OCCUPANT
CJ �1YC[ �� /�Ij�/v GROUP
C NUMBER NUMBER OF CRITICAL
OF DWELLING AREAS SPECIAL INSPECTION JAREA OCCUPANT
OSTORIES UNITS NUMBER REQUIRED ❑YES LOAD
DESCRIBE WORK TO BE DONE
REMARKS i
/1 /! PROGRESS INSPECTIONS PER UBC 108/IBC109/IRC109FINALINSPECTIONREO'D 91 01
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1 _
VALUATION
! $
Description FEE Description FEE .
Plan Check State Surcharge
HEAT SOU E GLAZIN % LOT SLOPE %
Building Permit City Surcharge
PLAN CHFCK NO: VESTED DATE Plumbing Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
tBE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC Grading
a DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION,
i Engr. Review
uM PERMIT APPLICATION: 180 DAYS
IL PERMIT LIMIT, 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr, Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION.
H 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS Fire Review Plan Chk, Deposit
2 IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND _ Fire Inspection 2 Receipt N
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECILY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
9 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape lnsp. Total Amt. Due
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.' S�
Recording Fee Receipt N (,3
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 inspac"provided.
WORKMEN'S COMPENSATION INS NCE AND RCW 18.27. (���� OFFI L SIG ATUR DATE
( SIGN URE (OWNER OR NT) DATE IGNED
✓ `' 771=0220 RELEASED 9 " DATE
ATTENTION EXT 1333
ITIS UNLAWFULTO USE OR OCCUPYA BUILDING OR STRUCTURE UNTILA FINAL
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OFOCCU- ORIGINAL -FILE YELLOW -INSPECTOR
PANCY HAS BEEN GRANTED, UBC109 / IBC110 / IRC110, PINK -OWNER GOLD -ASSESSOR
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