20050436.pdfI
DATE RECEIVED75�^
`& PERMIT EXPIRES`
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
W MAILING ADDRESS
CITY ZIP TELEPHONE
NAME
PERMIT i1/1 3
NUMBER (/"I �•6
JOB SUITE/AP a
ADDRESS
PLAT NAME/SUBDIVISION NO. LOT NO. /V ✓ LiDD NO C�
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApprored O
RW Permit Requwod 0
Street Use Permit Requwud 0
EXISTING PROPOSED Inspection Requited 0
—T— swfew.31k Rogwred 0
REQUIRED DEDICATION FT Undauground 0
Wum rx wrod 0
METER SIZE LINE SIZE NO, OF FIXTURES PRV REQUIRED
YE.;
D NOD Z
iY
W
REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE _
t7
%
L.
GiC_ k0.'t% r- Iic �- JU ENGINEERING REVIEWED BY DATE
ADDRESS
i q
�C L� FIRE REVIEWED BY DATE u
: CITY ZIP TELEPHONE i
q4 45 oft6b 14 Vj
STATE LICENSE NUMBER PIRATION DATE CHECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
REO'D COMPLETED I EXEMPT
N, ^� LA/ I �d 10YES D NO
J \
CAP ZONE SIGN AREA HEIGHT
PROPER�T%Y�TAXACCOUNT PARCEL NO.
LOO - STUDY13
WAIVER
ALLOWED PROPOSED ALLOWED PROPOSED
❑❑RESIDENTIAL PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
NEW ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
❑ COMMERCIAL ❑ t7
COMPLIANCE OR z
ADDITION ❑ CHANGE OF USE Z
MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REO'D PROVIDED
❑ . REPAIR ❑ GRADING ❑ FENCE
CYDS X FT.) REMARKS
❑ DEMOLISH ❑ TANK. ❑ OTHER
GARAGE RETAINING WALL LER
z ❑ CARPORT ❑ ROCKERY ❑ FIREALARM
IL SE,S(TYPE O BUS�T'IVA`ITY) EXPLAIN:
XE / ✓`��
TYPE 0ELDNSIEWCTION CADOCCUPANT
A7 5GROUP
w NUMBER NUMBER OF
OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
O STORIES UNITS / (/ / LOAD
REQUIRED Q YES
DESCRIBE WORK TO BE DONE
REMARKS z
GEOTECH REPORT m
BY:
f iv STRUCTURAL DESIGN
BY:
VALUATION
Description FEEDescription FEE
Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit O City Surcharge
PLAN CHECK NO: PlumbingZo 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 Gradin
J DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE g
t SEPARATE PERMISSION.
� Engr. Review
w PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
a 'PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engf. Inspection
rn 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
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 .f
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
2 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.* /
Recording Fee Receipt # 26
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 hislher Deputy: and Fees are paid, and
TION; AN IN DING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION receipt is acknowledged in ace provided.
IN VIOL 10 OF TH LABOR CODE OF THE STATE OF WASHINGTON RELATING TO P 0 p
WORK N'S 0 EN NSURANCE AND RCW 18!27. OFFICIALS SIGNATURE ATE
SIG T R W R AGENT): DATE SIGNED (425) S 2 6��-
771'022 OELSZ DATE
ENTION EXT. 1333
I I UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
INAL INSPECTION HAS BEEN MADE AND,APPROVAL OR A CERTI- ORIGINAL -FILE. YELLOW -INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC1091 IBC110 1 IRC1106 PINK -OWNER GOLD - ASSESSOR
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