20050449.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
MAILING ADDRESS
1401 1 7 1/6
CITY ZIP TELEPHONE
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NAME
ADDRESS
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CITY ZIP TELEPHONE
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NAME
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ADDRESS
PERMIT EXPIRES
USE PERMIT
ZONE L� NUMBER ��'/
JOB ' f SUITE/APT#
ADDRESS
PLAT NAME/SSUUB,DIVISION NO. LOT NO. LID NO.
LID FEE S
CP
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Pe Approved
RW Permit Required
Street Use Permit Req'd
EXISTING PROPOSED Inspection Required
Sidewalk Required
REQUIRED DEDICATION FT Underground
Witing required
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES ❑. NO ❑
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
ENGINEERING REVIEWED/DATE
FIRE REVIEWED BY DATE w
CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE C D BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION BOND
p r A REO'D POSTED
1 1� 1 f" Ci a{ L� l AJAR% � V1 ArP""m ❑ YES NO
SEPA REVIEW SIGN AREA HEIGHT
PROPERTY TAX ACCOUNT PARCEL NO. COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED
004-3 4 21110 1600 EXP I is IV � n0 Lhan 9P�
E] NEW ❑ RESIDENTIAL ❑ PLUMBING/ MECH LOT COVERAGE D SETBACKS (FT.) D SETBACKS (FT.)
ALLOWED PROPOSED FRIONZ REAR FRONT IJ *IDE REARI 1Z
ADDITION p� COMMERCIALr-1COMPLIANCE OR n D Lit an L✓) �5 `r o I S 82 106WW� I Z
❑ Id CHANGE OF USE •! z
PARKING LOT AREA PLANNING REVIEWED BY DATE g
REMODEL ❑ APARTMENT ❑ SIGN REO'D PROVIDED
FENCE no ung 0 Coo C�� 067 31/ C)!F
❑ REPAIR ❑ GRADING CYDS ❑ ( X FT) REMARKS
11 re 10" back = I a
[3 DEMOLISH C]OTHE TANK w� G
1 *9Ic u tits rn ten♦ e�-d I to. 3 0. a y -a D
[DGARAGE RETAININr
CARPORT ❑ G WALL RENEWAL
❑ P� Pp�CG� dct* p e&4!0 50 *2051 3.33' so b 1--),
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
CHECKED BY ITYPECONSTRUCTION CODE OCCUPANT
DOM IJ) u GROUP /1
NUMBER NUMBER OF CRITICAL 2
OF DWELLING i/ AREAS SPECIAL INSPECTOR AREA OCCUPANT
STORIES UNITS T NUMBER REQUIRED ❑ YES LOAD
DESCRIBE WORK TO BE DONE
1 ✓ W REMARKS _
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D o
S x.1171 W Er �rL.�l-.:.5 0012- s
In
VALUATION FEE
PLAN CHECK FEE
HEAT SOURCE GLAZING % LOT SLOPE °6 BUILDING
114 if
PLAN CHECK NO: ^ VESTED DATE .arorlaG'
GMECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC GRADING/FILL
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.).WILL REQUIRE
F SEPARATE PERMISSION.
h STATE SURCHARGE C,l I /
cc PERMIT APPLICATION: 180 DAYS
W
6 a PERMIT LIMIT:1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
in •APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS ENG. INSPECTION FEE
W
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF LANDSCAPING]Tfff;
2 EDMONDS. WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND INSPECTION F E (�L/
cc
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
RECEIPT
= FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE PLAN CHECK DEPOSIT
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
X01 NOR LIMIT IN ANYWAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION." RECEIP /
TOTAL AMOUNT DUE
(2kj
I HEREBY ACKNOWLEDGE THAT I HAVE. READ THIS APPLICATION; THAT THE INFORMATION APPLIC TION APPROVAL
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
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 are paid. and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S COMPENSAT9,UI17SYRANCE AND RCW 18.27.
(425) OFFI SIG E DATE
SIGNATURE (OWNER OR ENT) DATE SIGNED `7�'
771=0220 &M
RE ED BY D E
ATTENTION EXT 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771 _0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL- FILE YELLOW - INS ECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED, UBC SECTION 109 FAX PINK -OWNER GOLD- ASSESSOR
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