20050208.pdfDATE RECEIVED
PERMIT EXPIRES J G'.
PERMIT
CITY OF EDMONDS NUMBER �% l%7J
CONSTRUCTION PERMIT APPLICATION JOB UiTE/APT#
ADDRESS
OWNER NAME/NAME OF BUSINESS77* Deeewyebe �/� i // /•_ T7
Gin [ � N , PLAT NAMEISUBDIVISION NO, LOT/6 LID NO,
MAILING ADDRESS I + r/ 7 LID FEE S
�JiD PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved O
v J RW Permit Required 0
Seeel Use Permit Requited E3
CITY ZIP TELEPHONE EXISTING _PROPOSED _ Inspection Required 0
Sidewalk Required O
A ds VI g 2LZ Q REQUIRED DEDICATION FT U dergrrwnd O
NAME METER SIZE LINE SIZE NO. OF IXTURES PRV REQUIRED
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NAME
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REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE _
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ENGINEERING REVIEWED BY
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FIRE REVIEWED BY DATE
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STATE LICENSE NUMBER EXPIRATION DATE C VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
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m s. (f v " qui 1 �"� d � at - O YES
PROPERr. TAX ACCOUNT PARCEL NO. CA# ZONE SIGN AREA HEIGHT
_ - WAIVER-- ALLOWED PROPOSED ALLOWED PROPOSED
STUDY D 6 1 �;; � I
L NEW ❑ RESIDENTI LUMBING 446*0a LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
dCOMMERCIAL COMPLIANCE OR i
❑ ADDITION ❑ CHANGE OF USE i
❑ MIXED USE PARKINGLOT AREA PLANNING REVIEWED BY D TE g
�EMODEL ❑ MULTIFAMILY ❑ SIGN REQ'0 PROVIDED
❑
GRADING FENCE REPAIR ❑ CYDS ❑ ( X FT.) REMARKS
❑ DEMOLISH ❑ TANK ❑ OTHER
❑GARAGE RETAINING FIRE
CARPORT ❑ ROCKERY WALL ❑ FIREALARM SPRINKLER
JW 4 TYPE OF CONSTRUCTION CODE GROUP OCCUPANT
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NUMBER NUMBER OF G"
OF DWELLING VAY SPECIAL INSPECTION CONSULTANT OCCUPANT
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STORIES / UNITS LOAD
7 REQUIRED 13YES
DESCRIBE WORK TO BE DONE
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�' Plan Check ` State Surcharge o
HEAT SOURCE IAT SLOPE% VESTED DATE —.
4A4 Building Permit City Surcharge i
PLAN CHECK NO: /�'� ��i, _,y Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO MBChanICBI
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
f DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE Grading
t SEPARATE PERMISSION.
s Engr.. Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
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a PERMIT LIMIT: SEE ECDC 19,00,005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engr. Inspection
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•APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review r') " Plan Chk: Deposit
W IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF _
i EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection % Receipt #
a ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY +
= FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE
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DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due L
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.•
Recording Fee Recept #i ,
I HEREBY ACKNOWLEDGE THAT 1 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. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or his/her ged n Deputy: space provided.
and Foes aro paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged
WORKMEN'S COMPENSATI0�1 I RANCE AND RCW 18:27.
%IC SIG URE DATE
SIGNATURE (OWNER DAT SIGNED .(425) C-40?4
z 771 -0220 EL A ED BY DATE
ATTENT EXT. 1333 1,
ITIS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL - FILE YELLOW - INSP CTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 I IBC110 / IRC110, PINK -OWNER GOLD - ASSESSOR
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