20050493.pdfDATE RECEIVED
6-16 03 PERMIT EXPIRES
USE PERMIT
CITY OF EDMONDS ZONE NUMBER 6�6(-'
JOB SUITE/APT#
CONSTRUCTION PERMIT APPLICATION ADDRESS
OWNER NAMENAME OF BUSINESS
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
CAC.�
um MAILING ADDRZ I
LID FEE $
TESCP AppriTv-0d [3
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Required
L5 'A c� Street Use Permit Roq'd
0 —1 , —
CITY ZIP TCEPHON EXISTING — PROPOSED inspection Required C3
Sidewalk Required E3
Underground
L
4 REQUIRED DEDICATION— FT Wiring required
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES 13 NO El
W
z
ADDRESS REMARKS z
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROWDRAINAGE
z
TE LEPHONE
CITY ZIP
Vio NirlVlrlecl ml Gt�e .4kPDA �c,-�Oae
NAME
CBL #
4�; 1
wt
IV a=(e?y'nA
ENGINEERING REVIEWED BY DATE
ADDRESS
FIRE REVIEWED BY DATE
W
M
CITY
L% Zip
90
TELEPHONE
I (4 2 5) _71 1 kA'-2> L
rL
VARIANCE OR CU
SHORELINE ORAD1111
INSPECTION
REQ'D
B�OND
POSTED
I
STA1\EJLICENSE NUMBER EXPIRATION DATE
C Y
c)-.[.-? C) 9
EIYES NO
SEPA REVIEW
SIGN AREA
HEIGHT
PROPERTY TAX ACCOUNT PARCEL NO.
EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
,o 7'7- 'I'Alo-TCO
I
I
EXP
NEW
RESIDENTIAL
PLUMBING MECH
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (Fr.)
FRONT SIDE REAR
PROPOSED SETBACKS (Fr.)
FRONT UR SIDE REAR
ADDITION
COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
REMODEL
G"ULTIFAMILY
SIGN
PARKING
REO'D PROVIDED
I
LOT AREA
PLANNING REVIEWED BY DATE
IL
[] GRADING FENCE
REPAIR CYDS X F7)
REMARKS
DEMOLISH TANK ER
Z-09IX-PL&C-C
GARAGE RETAINING WALL FIRE SPRINKLER
CARPORT ROCKERY FIRE ALARM
(TYPE OF USE. BUSINESS OR ACTIV" E);PLAIN:
I
NA-v ck / (, ()
CHECKED BY
TYPE OF C0ffZM'.
OCCUPPT
GROUg
NUMBER
OF
NUMBER OV
DWELLING
—
CRITICAL
AREAS
SPECIAL INSPECTION
AREA
OCCUPANT
STORIES
UNITS
NUMBER
REQUIRED YES
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D
0-i
VALUATION
oc
Description FEE Description FEE
Plan Check
State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %
Building Permit Rc�
city Surcharge
PLAN CHECK NO: VESTED DATE
Plumbing
Mechanical
C-)o
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
tz BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
2
Ir
UJI PERMIT APPLICATION: 160 DAYS
93. PERMIT LIMIT I 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
X EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
IALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF THIS PERMIT SHALL NOT BE
91 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
Landscapelnsp.
Total Amt. Due I �Q o
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
x
Fee
Receipt #
Recording
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
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 are paid, and
!ON OF THE4.4k
IN VIOLAT OR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
receipt is acknowledged in space provided.
WORKMENS COMPENSA3JOIZ�SIJ RANCE AND RCW 18.27.
J�FICJ7
SZIGTUR DATq
mm�
Sit URE (OWNER;06AGENT) DATE SIGNED
(42 5)
LD
771-0220 DATIt
RELJ�-"Y
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 CERTIFI-
ORIGINAL - FILE YELLOW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
PINK.- OWNER GOLD - ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES
GREEN - ACCOUNTING
z
0
1
0
IT!
-n
C/)
X
M
M
0
10
0 C
X M
M Z
jc) --I
C _z
0)
o -n
n
M ITI
0 5)
0 r,
0 IT11
cl)
ITIO,
Z
z
--I
x
0)
z
0
--I
0
IT!