20050274 (2).pdfDATE RECEIVED /+
1"o 5� PERMIT EXPIRES �� ^
PERMIT �,�
CITY OF EDMONDS NUMBER -3 L]
CONSTRUCTION PERMIT APPLICATION JOB ADDRESS J SUITE/APT#
OWNER NAMEINAME OF BUSINESS �� 4q7l 3f.�
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
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MAILING ADD ESS LID FEE 5
o C� i PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved
RW Permit Required p
Street Use Permit Requited 13,
CITY ZIP TELEPHONE EXISTING _ PROPOSED ___ Inspection Required O
i Sidewalk Required O
1 n� Underground E3
r / P '� REQUIRED DEDICATION FT Wifing requited O
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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YES D NOD z
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ADDRESS REMARKS w
u OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE z
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CITY ZIP TELEPHONE
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41" 1 C7 'flolotI&IOV1040V
NAME CBL#
ENGINEERING REVIEWED BY DATE
ADDRESS
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CITY FIRE REVIEWED BY DATE
ZIP TELEPHONE it
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VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA I
STATE LICENSE NUMBER ,EXPIRATION CHECKED BY I _
REO'D COMPLETED EXEMPT
DYES 0 NO 1 �
PROPERTY TAX ACCOUNT PARCEL NO. CA# ZONE SIGN AREA HEIGHT 3:
a ^ - WAIVERS ALLOWED PROPOSED ALLOWED PROPOSED I C.M
!� ��STUDY [3 M O .
RESIDENTIAL LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.) "•) n .
❑ NEW Ef PLUMBING/ MECH ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR O C
COMMERCIAL COMPLIANCE OR z
.❑ ADDITION ❑ z I = m
❑ MIXED USE CHANGE OF USE z m Z
❑REMODEL PARKING LOTAREA PLANNING REVIEWED BY DATE g
❑ MULTIFAMILY ❑ SIGN REO'D PROVIDED a C �
❑ REPAIR ❑ GRADING ❑ FENCE r
CYDS ( X FT.) REMARKS // L.w �,it a yr �P
OTHER / �J l�V C"
❑ DEMOLISH ❑ TANK 1:1��/ O m
I GARAGE RETAINING WALL FIRE SPRINKLER (O�
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❑ CARPORT ❑ ROCKERY ❑ FIRE ALARM
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(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
ATYP F CONSTRU ION jj C ANT jT1
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m OF DWELLING ��� SPECIAL INSPECTION CONSULTANT LOAD OCCUPANT n m'
O STORIES UNITS C M
DESCRIBE WORK TO BE DONE , REQUIRED O YES
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S ZvC�.� C1�ia,/ REMARKS_ 1 Z 0
IL GL r GEOTECH REPORT m
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1z"e%�rtlC VALUATION z
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Description FEE Description FEE I
Plan Check State Surcharge -�
HEAT SOURCE LOT SLOPE% VESTED DATE M .
Building Permit City Surcharge
PLAN CHECK NO: Plumbing ) — Base Fee
Mechanical / f��/�'�
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO L� t r LU
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
i DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
j SEPARATE PERMISSION.
s Engr. Review
W PERMIT APPLICATION: SEE ECOC 19.00.005(A)(5)
a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
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*APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
uj 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
0 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due Z)
Q NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee Receipt #
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
GIVEN IS CORRECT; AND THAT 1 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 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 spare provided:
WORKMEN'S C NSATION INSURANCE AND RCW 18:27.
OFFICIALS SI NATURE DATE
SIGNAT O ENT)' DATE SIGNED (425)I /Z
104 311 771 =0220 RELEASE DATE
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 CERTI- ORI - FILE . YELLOW • INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 if IBC110 1 IRC110. PINK • OWNER • GOLD • ASSESSOR
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