20050406.pdfDATE RECEIIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICAT
OWNER NAME/NAME OF BUSINESS
MAILING ADDRESS
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CITY ZIP ITELEPHONE
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)� PERMIT EXPIRES V1 ( I
101111101
USE PERMIT
ZONE NUMBER
JOB SUITE/APT#
ADDRESS '
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PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
1Q I VV 3k LID FEE $
TESCP
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW RW Pe Approved p
- rmlt Required [)
Street Use Permit Roq'd p
EXISTING PROPOSED Insportion Required
Sidewalk Required
REQUIRED DEDICATION FT Underground
Wiring required 0
F NAME `' METER SIZE LINE SIZE N0. OF FIXTURES PRV REQUIRED
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OWNER/CONT4MVI&6}I6Bi0'fROL/DRAINAGE Z
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NAME 11 1 C1009
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C .ADDRESS
FIRE REVIEWED BY DATE w
CITY ZIPTELEPHONE
STATE LICENSE NUMBER p,r� /'� � XPIRAT N DATE K D Y VARIANCE OR CU SHORELINE ORA INSPECTION BOND
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POSTED
NINE SEPA REVIEW SIGN AREA HEIGHT
PROPERTY TAX ACCOUNT PARCEL NO. COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED
00
EXP
❑ NEW ❑ RESIDENTIAL NPLUMBINGMPLIANCE OR /MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR O
ADDITION OMMERCIAL =
❑ (� 1:1z
""\CCHANGE OF USE z
PARKING LOT AREA PLANNING REVIEWED BY DATE S
L ❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED
❑❑ GRADING ❑ FENCE X FT) REMARKS
REPAIR CYDS (
❑ DEMOLISH ❑ TANK 1:1 OTHER
RAGE RETA❑ CARPORT ❑ R CKIERY NING WALL ❑� FIRE ALARFIRE NKLER
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(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
u J� CHECKED BY TYPE 0 N TRUCTION COpy7 OCCUPANT
c NUMBER IV `NUMBER OF CRITICAL LJ�
OF DWELLING AREAS A e SPECIAL INSPECTION AflEA OCCUPANT
O STORIES UNITS NUMBER N y A REQUIRED YES LOAD
DESCRIBE WORK TO BE DONE
REMARKS 9
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PROGRESS INSPECTIONS PER UBC 108/IBC109/IRC109FlNALINSPECTIONREO'D
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L'WQ_64 1VON VALUATION
$
Description FEE Description . FEE
Plan Check State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE % Building Permit City Surcharge ?`
PLAN CHECK NO: VESTED DATE Plumbing Base Fee
0W
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
C BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
7 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION.
a Engr. Review
PERMIT APPLICATION: 180 DAYS
d PERMIT LIMIT. 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr, Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
•APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS Fire Review Plan Chk. Deposit
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, ARIS114G DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
j DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE LandSCape lnsp. Total Amt. Due
= NOR LIMIT IN ANY WAY THE C17Y'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
Recording Fee Receipt Ii
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 APPROVAL
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 aro paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEMS COMPENMI IO URANCE AND RCW 1827.
OFFICIALS SIGNATURE DATE
TURE (OWNER OR A EN DATE SIGNED
(425)
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EASE Y DAT
ATTENTION EXT 1333 C
ITIS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL ;� I
INSPECTION HAS BEEN MADEANDAPPROVALORACERTIFICATE OFOCCU-
PANCY HAS BEEN GRANTED, UBC109 / IBC110 / IRC110. \ INK - O N YG L D - INSPECTOR
PINK -OWNER GOLD -ASSESSOR
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