20050355.pdfiFlvp�
DATE RECEIVED
CITY OF EDMONDS
PERMIT EXPIRES
USE PERMIT
ZONE
NUMBER JG�Gr�—(/
CONSTRUCTION PERMIT APPL11CATION JOB _ SUITE/APTJI
DDRESS 'rr �/( �I
OWN
E
R
,N�AME/NryAME OF BUSINESS I I
1 � l `� 13o �� �L �(JV<<j PLAT NAME/SUBDIVISION N0. LOT NO. LID NO.
MAILING ADDRESS
j LID FEE $
V�!/PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved QRW Permit Required 0
CITY Street Use Permit Roq'd QZIP TELEPHONEEXISTING PROPO D Inspection Rd uired u
Sidewalk RequiredREQUIRED DEDICATION � FT Underground
NAME Wiring required Q
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES ❑ NO 13z z
ADDRESS
FE
REMARKS z
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE z
CITY•' ami
ZIP TELEPHONE 0CpCiId.0 'O 450 VV -1)
r SG' l"f l 012 �a
NCBL
AME L
%Z(4SSr:.LL /I CK a triAL
S ,nd,
ADDRESS ENGINEERING REVIEWED BY
O� ATE
)Me
sz)� r 2C)6 > j l�FG l _5 AA/ / ?.v4S
U 1)CITY �,n,� ZIP / TELEPHONE FIRE REVIEWED BY W
.,, % Mn ', �%G/L' % / �D � (O '' � • DATE ML
a� 775 7Gi!O
STATE LICENSE NUMBER IEXPIRATI N DIEVARIANCE OR CU SHORELINE O Bp INSPECTION BOND
�ZL455 CSC, 0001>F;7Y
.t �� ■m.�--„�✓ REQ'D POSTED
ONO S
a PROPERTY TAX AC UNT PAR SEPA REVIEW SIGN AREA HEIGHT
W COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED
J EXP
❑ NEW ❑ RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWEDPROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
❑ z ADDITION COMMERCIAL ❑ COMPLIANCE OR �.- -� Z
CHANGE OF USE z
z
❑ REMODEL ❑ MULTIFAMILY SIGN REQ'p PARK I ROVIDED LOT AREA PLANNING REVIEWED BY DATE a
❑ REPAIR ❑ GRADING CYDS ❑ FENCE
( X FT) REMARKS
❑ DEMOLISH ❑ TANK OT N
GARAGE RETAINING FIRE SPRIzz ❑ CARPORT ❑ ROCKERY WAIL ❑ FIRE ALARM LER
(TYPE OF USE, BUSINESS ,OF� IV EXPLAIN:
Q C/� ]v CHECKED BY ITYPEar)F NSTRUC 10 C� OCCUPA
UGROUP
NUMBER NUMBER OF ( CRITICAL t
to OF ' DWELLING `I v AREAS 'v SPECIAL INSPECTION AREA OCCUPAI
O STORIES UNITSLOAD
NUMDI, YE
REQUIRED ❑ S LOAD
DESCRIBE WORK OBE DONEI- y
i
s z 7 REMARKS r7
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REG'D
N: 1 s
VALUATION
Description FEE Description FEE
Plan Check14 `I`IIIIIIIW
State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %
Building Permit City Surcharge
PLAN CHECK NO: /n VESTED DATE Plumbin
g Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO Mechanical
i BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
J DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
I. SEPARATE PERMISSION.
Engr. Review
W PERMIT APPLICATION: 186 DAYS
PERMIT LIMIT, 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engr. Inspection
y 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS Fire Review Plan Chk. Deposit •r
u� IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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 _
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp, Total Amt. Due )
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.•
Recording Fee Receipt k
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF APPLICATION APPR AL
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 Foes aro paid, and
IN VIOLATION OF THE LABO CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt Is acknowledged in space provided.
WOj1K COMPENSA I RANCE AND RCW 18.27.
FIC S SIGNAT E DATE
SI�NATU (OWNER VGENT,,)/
DA SIG D /42iJ�/\ ee��. l� C/ 771 -0220. RE BY E
ATT ON EXT 1333 /
IT IS NLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI
CATE OF OCCUPANCY HAS BEEN GRANTED, UBC SECTION 109 ORl I - FILE YELLOW -IN PE TOR
PINK -OWNER GOLD -ASSESSOR
os�os PRESS HARD =YOU ARE MAKING 4 COPIES