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7 �1 PERMIT EXPIRES l
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CITY OF EDMONDS Nu BER % ; �� -�i �' �✓
CONSTRUCTION PERMIT APPLICATION JOB
O DRESS _ SUITEIAPTn
OWNER NAME//NAME OF BUSINESS
c� 41 / PLAT NAME/SU IVISION NO LOT NO LID NO.
m MAILING ADDRESS LID FEE 5
�`-•� -•�' r% tESCPApprovad ❑
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
O \: uJ ' IG Ct•/ Z -S RW Permit Required ❑
Street Use Permit Requited ❑
CITY ZIP TELEPHONE EXISTING — PROPOSED Inspection Required ❑
,-~ 1 Srdawalh Requited ❑
REQUIRED DEDICATION -- FT underground ❑
— Wiring required ❑
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES IJ NO O K.
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ADDRESS REMARKS
U OWN CONT ACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE E5
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CITY ZIP TELEPHONE
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NAME � / � CBS J % L
/ / ✓� l t/� i /1Zl /�' �� '� I ENGINEERING REVIEWED BY DATE
m0 ADDRESS
FIRE REVIEWED BY DATE
= CITY ZIP TELEPHONE it
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STATE LICENSE NUMBERCHECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
9 REQ COMPLETED EXEMPT
/ G21C1/JZ_ ZC 0•J 10YES NO
-j PROPERTY TAX ACCCC���UNT PARCEL NO. CA# ZONE SIGN AREA HEIGHT
W- /1 /_ , ;� ` ��, \ WAIVER O ALLOWED PROPOSED ALLOWED PROPOSED
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❑ NEW❑ RESIDENTIAL PLUMBING / UIRED MECH LOT COVERAGE REQSETBACKS (FT) PROPOSED SETBACKS (FT.)
❑. COMMERCIAL COMPLIANCE OR ?
❑ ,ADDITION ❑ CHANGE OF USE ��� z ry
MIXED USE �T t ►A� p[5�g± �pRB� try
❑ REMODEL MULTIFAMILY ❑ SIGN R 'D PR�DEl7 jl�j Li its � .i:1�yL- Mrj PIZCP09DE►�✓y g
❑ REPAIR ❑ GRADING ❑ FENCE "tRE ZETA WATER SERVICE
CYDS OTHER � g� �rT
( X FT.) R A'�f'fN0 .'�S USED FOR ELECTRICAL
❑ DEMOLISH ❑ TANK ❑ CT.WUNDIN i PUP%.P
GARAGE RETAINING WALL FIRE SPRINKLER V V lY 1J 1 V
_ ❑ CARPORT ❑ ROCKERY ❑ FIREALARM li 1 ►� i L i' _!\V
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a (TYPE OF USE, BUSINESS QE C
O CTIVITY) EXPLAIN: � _q__
w NUMBER NUMBER OF E S bN IS !Mg
G TELECT"IUCAL
OF DWELLING S CI S
p STORIES UNITS
DESCRIBE WORK TO BE DONE R uWAZWE Q;t ADDED C(? AST STATE
RE ARDEf'T OF LABOR & I.N DUSIlUES tUCAL
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G t/ GE TECH REPORT
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BY:
STRUCTURAL DESIGN
BY:
VALUATION
$
Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE _
Building Permit ) City Surcharge
PLAN CHECK NO: Plumbing 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 PUBIC
f DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION.
Engr. Review
W PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection�1 SEE BACK OF PINK PERMIT FOR MORE INFORMATION
in *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
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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
m 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 #
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-
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or his/her Deputy: and Foes are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION i receipt is acknowledged in space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27. �"
i FF W S SIGN URE T
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SIGNAT NER O GE T): DATE SIGNED (425) Zp;/ / lee`5
771m0220 RtLIzAtitU B r DAT.:
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- ORIGINAL -FILE YELLOW •INSPECTOF
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC1091 IBC110 / IRC110, PINK • OWNER GOLD • ASSESSOR
10104 PRESS HARD' - YOU ARE MAKING 4 COPIES
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING.DIVISION
FROM: FIRE DEPARTMENT DATE
PLEASE SIGN z. r
ENGINEERING DIVISION DATE
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PLANNING:DIVISION DATE
PLEASE SIGN
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PROJECT Oil, irm m o
SITE ADDRESS --i
S'O ADB# DATE.INSPECTED �PI �1 O m z
PERMIT # .a U A
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DESCRIPTION OF.WORK.TO BE INSPECTED
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A field inspection was conducted to determine compliance with approved plans. Final approval
denotes that there. are no objections 'froth . the above signed Department to the release of
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PERFORMANCE BONDS and the granting of: vo (n
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GRANT FINAL PROJECT APPROVAL Z
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GRANT PROJECT APPROVAL WITH CONDITIONS NOTED _
❑ Copy of CONDITIONS given to owner/contractor by inspector zz
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DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING.DIVISION
FROM: FIRE DEPARTMENT DATE
PLEASE SIGN z. r
ENGINEERING DIVISION DATE
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. .. PLEASE SIGN c .. rn
PLANNING:DIVISION DATE
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PROJECT Oil, irm m o
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PERMIT # .a U A
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DESCRIPTION OF.WORK.TO BE INSPECTED
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A field inspection was conducted to determine compliance with approved plans. Final approval
denotes that there. are no objections 'froth . the above signed Department to the release of
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PERFORMANCE BONDS and the granting of: vo (n
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GRANT FINAL PROJECT APPROVAL Z
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GRANT PROJECT APPROVAL WITH CONDITIONS NOTED _
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