20050222.pdfDATE RECEIVED PERMIT EXPIRES
PERMIT
CITY OF EDMONDS NUMBER -�-- (.
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CONSTRUCTION PERMIT APPLICATION JOB SUITE/A??#
ADDRESS�,�2 8 d 711A
00 Ave
OWNER NAME/NAME OF BUSINESS. 7Lf
Si., I" , PLAT NAMEISUBDIVISION NO, LOT NO, LID NO
MAILING APDRESS I LID FEE
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApptovpd [3
RW Permit Requited [3
4?Qez��_ Street Use Parind Required E3
CITY ZIP TELEPHONE EXISTING PROPOSED inspection Requited E3
Sidewalk Requirect 0
REQUIRED DEDICATION FT Undertpound E3
I ilolmlya Wiring requited E3
NAME % METER SIZE LINE S17ETO. OF FIXTURES PRV REQUIRED
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ADDRESS REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE z
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CITY ZIP TELEPHONE
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q7OqENGINEERING REVIEWED BY DATE
ADDRESS
'331D FIRE REVIEWED By DATE W
CITY Z TELEPHONE
itq6 1P :3jq— VARIANCE OR CU SHORELINE OR ADBY INSPCCPON SEPA
STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY REQ D COMPLETED I EXEMPT
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ROP R 17 WAIVER 13 ALLOWED PROPOSED ALLOWED PROPOSED
1.) STUDY 13
NEW El RESIDENTIAL PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT L/RSIDE REAR
COMMERCIAL COMPLIANCE OR z
ADDITION xr-n CHANGE OF USE I I E
ElMIXED USE z
PARKING LOTARE LANNING REVIEWED BY DATE 5
MULTIFAMILY SIGN REQ'D I PROVIDED 9L
GRADING FENCE
E] REPAIR El CYDS 1:1 ( X FT.) REMARKS
OTHER
EMOLISH TANK
GARAGE E:i RETAINING WALL FIRE SPRINKLER
CARPORT ROCKERY FIREALARM
(TYPE OF USE, BUSINESS OR ACTIVITY EXPLAIN:
3 A--, TYP"F CONSTRUCTION C CUPANT
itl%4troov— GROUP
NUMBER NUMBEROF oc
OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES UNITS A/4 1:1 YES LOAD
REQUIRED
DESCRIBE WORK TO BE DONE REMARK�
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Vt GEOTECH REPORT
BY:
Ax+V or STRUCTURAL DESIGN
BY:
VALUATION
$
Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LOTSLOPE% VESTED DATE 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
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION.
Engr Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
tn 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
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W
i IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
M EDMONDS. WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
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 Landscapeinsp. Total Amt. Due
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0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
xi Recording Fee Receipt # r ;401
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. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL Building Official or his/her Deputy: and Fees are paid. and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED receipt is acknowledged in space provided.
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FO NSP"RT19N
WORKMEN'S COMPENS/41f N INSU. AND RCW 18:27.
0 jALS SIGNATYRE DqE
I DATE SIGNED
SIGNATURE N (425) _y;N
771-02.20 REL AS
ATTENTION EXT. 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UN L
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERT
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 if IRC110.
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
ORIGINAL -FILE YELLOW -INSPECTOR
PINK -OWNER GOLD - ASSESSOR
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