20050246.pdf'n. ) DATE RECEIVED
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
MAILING ADDRESS
921-0.1ft _1A)
CITY 21P TF[ FPHONS
NAME
ADDRESS
x
CITY ZIP
NAME
ADDRESS
CITY
STATE LICENSE NUMBER
TELEPHONE
PROPERTY TAX ACCOUNT PARCEL NO.
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NEW
RESIDENTIAL
ADDITION
COMMERCIAL
REMODEL
MULTIFAMILY
REPAIR
GRADING CYDS
DEMOLISH
TANK
oGARAGE
RETAINING WALL
CARPORT
ROCKERY
[TYPE OF USE, BUSINESS TTIVITY) EXPLA llf.
NUMBER
NUM13ER OF
OF
DWELLING
STORIES
UNITS
DESCRIBE WORK TO BE DONE
19930
CBL #
94q
PERMIT EXPIR�?ql
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USE
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PERMIT
NUMBER d CQ
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JOB
A o D R E S S
ADDRESS c�2
SUITE/APT#
1 '711 -7 W
A M E
PLAT NAM EISU BDIVI
P LA T N
Ii.
SION NO.
LOT NO.
LID NO.
LID FEE S
R IG
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
P U B L I C
TESCP Approved
AW Permit Required
E3
13
r X STI No
EXISTING
PROPOSED
Street use Permit Roq'd
Inspection Required
Sidnwalk Required
L3
13
13
REQUIRED DEDICATION—
FT
Underground
Winng required
E3
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES 13 NO 1:3
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REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROL /D RAINAG E
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W
x, vent connector required
fjj&�hrnldg RP01,flinces passing
rj%G EVIGM3.
I&N. WMIlielitted spaces.
FIRE REVIEWED BY
DATE
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IX
PHONE
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VARIANCE OR CU
SHORELINE OR AD13N
I INSPECTION :
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OYES EINO
S
.'BOND
POSTED
1
0
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IATION DA7E
SEPA REVIEW
COMPLETE EXEMPT
SIGN AREA
ALLOWED PROPOSED
HEIGHT
ALLOWED , PROPOSED
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EXP I
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0
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APLUMBING MECH
COMPLIANCE OR
El CHANGE OF USE
FDIED
SIGN
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (Fr.)
FRONT SIDE REAR
PROPOSED SETBACKS (FF.)
FRONT QRSIDE REAR
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1 2
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PARKING
REO'D PROW
LOT AREA
PLANNING REVIEWED BY DATE
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FENCE
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REMARKS
OTHER
FIRE SPRINKLER
FIRE ALARM
X
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CHECKED BY ITYPE OF CONSTRUCTION CODE OCCUPANke:�
GROUP
CRITICAL 03
AREAS SPECIAL INSPECTION JAREA OCCUPANT X
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NUMBER REQUIRED [] YES LOAD 0 —
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17-
REMARKS z 0 M
PROGRESS INSPECTIONS PER UBC 108/ IBC109/ IRC109 FINAL INSPECTION REO'D C co
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Description
FEE
Description
FEE
112i!N .
Plan Check
State Surcharge
HE OU CE
GLAZING
1
Le? SLOPE %
Building Permit
City Surcharge
Plumbing
BaseFee
PLAN ECK NO:
C
VESTED DATE
Mechanical
Jao_-
0_
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t BE DONE ON PRIVATE PIROPEFrry ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
2 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
W PERMIT APPLICATION: 180 DAYS
IL PERMIT LIMI*P 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
U) 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
Fire Review
Plan Chk. Depo�ft
q IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 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
Landscapelnsp.
Amt. E
Total Amt. Due
DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
Le
01 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENF013CE ANY ORDINANCE PROVISION.-
x
Eotal
—
Recording Fee
R c ipt #
Receipt #
e
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
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'!��NSATION,�SURANCE AND RCW 18.27.
OP DATE
's
s TU (OWNER DATE SIGNED
(425)
tRE
NIAL71,14 ._2
YR
771 -0220
DATE
RELEAe
AftENTION'
Off 1333
\jBY
IT IS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE AND APPROVALOR A CERTIFICATE OF OCCU-
ORIGINAL - FILE - YELLOW - INSPECTOR
PANCY HAS BEEN GRANTED. UBC10q/IBC110/IRC110.
PINK -OWNER GOLD -ASSESSOR
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