20050641.pdfDATE RECEIVED
I J PERMIT EXPIRES r
CITY OF EDMONDS
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CONSTRUCTION PERMIT APPLICATION SUITE/APTa
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OWNER NAMEINAME OF BUSINESS
'1\AQc2�` C���� �� E/SUBDIVISION NO. LOT NO. �3 LID NO.
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MAILING ADDRESS 6: W oob �iL LID FEE 5
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CITY ZIP TELEPHONE CAI PROPOSEDSheol Use Permd RRgmred ❑ Inspection Required ❑SR1ew.tlk Required ❑
� C33 �e 2C -'%D DEDICATION FT --• undnrground ❑Winn re uired ❑
NAM SIZE LINE SIZE NO�OJF FIXTURES PRV REQUIRED
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STATE LICENSE NUMBER EXPI TION 9ATECHECK D BY VARIANCE OR CU SHORELINE OR ADBN INSPECTION SEPA
REQ'D COMPLETED EXEMPT
0 YES N NO
a PROPERTY TAX ACCOUNT
�PARCEL NO. CAN OS•Q(} _ ZONE
WAIVER . SIGN.AREA HEIGHT
wa� ^ �yU STUDYI' �rJ• `/i ALLOWED PROPOSED ALLOWED PROPOSED
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NEW 15ZRESIDENTIAL PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT LIR SIDE REAR
❑ ADDITION LJ COMMERCIAL ,
COMPLIANCE OR !, 0
❑ MIXED USE 1:1CHANGE OF USE Z
PARKING PLANNING REVIEWEDBY DATEREMODEL MULTIFAMILY SIGN REO'D PROVIDED �S FENCEJ,LOTAREA
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REPAIR D N CYDS ❑ ( X FT.) REMARKS •�
OTHER
❑ DEMOLISH ❑ TANK ❑ y. p r y I ,y.,,
�ARAGE ❑ RETAINING WALL ❑ FIRE SPRINKLER T a�� YY� a ro Civ� ((3 WI 1 r/ m
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CL (TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAI .
�1. TYPE F RUCTION GROUPANT .
wNUMBER NUMBER OF
OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
MSTORIES UNITS REQUIRED 13YES LOAD
DESCRIBE WORK TO BE DONE
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STRUCT
VALUATION
Description FEE Description FEE
Plan Check State Surcharge �0
HEAT SOURCE LQT SLOP °o VESTED DATE
, ' Building Permit ' City Surcharge �•, 0
PLAN CHECK NO: Plumbing Base Fee �V
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical i O
t BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBIC I
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
J SEPARATE PERMISSION,
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W PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5) Engr. Review
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a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Inspection
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SEE BACK OF PINK PERMIT FOR MORE INFORMATION cccJJJ ���JJJ✓
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit 9a,99
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IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt # lQ
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
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 ov2
x 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
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 DOI E WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED Building Official or his/her Deputy and Fees are paid, and
IN VIOLATION .THIII LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged In space provided.
WORKMEN' 34OMPENIATION INSURANCE AND RCW 18:27.
FI S SIGNAT E DATE
LSIGNATURI WN AGENT): DATE SIG ED (425) I/
� l ` % Z � ��5� 771 w0220 ` RELEV7 IAh
ATTENTION EXT. 1333
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IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI-
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 I IRC110.
lo/04 PRESS HARD = YOU ARE MAKING 4 COPIES
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THC WeT 9400 FELT Q 3e, MAPL HILLe, ACCORDM TO TF! 1 \ I .
PLAT THEREOF RECOILED N VM" OF PLAT*, PAGE 121,
s RECOICe O. 01OHOM04 COUNTT, TON
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_ excePT THE *OUTH 100 FLET THEREOF _ I 74• - n FIR
. .SLEI&CT TO EA80o" B, REOTRICTIONe AND REeERVAT"O Q CORD HR •
Lot Goveragif.OT AREA 13x01 *QUARE RCT �
.OT COVERAGE 9813 *OIARE FEET
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mcg peDjtt�t 5 infix RECEIVED
CI Yer�uirid 5�t'bac,!✓ 3.33'
�'" if under 30" cin h CA 9 Vol t JUN 15 2005
PERMIT COUNTER
Permit Fee's Collected at Permit issuance
# of Inspections: X $50.00 = $ 55D °�'
Receipt#:
Receipt Copy Attached: Y / No
Inspection Fee's. TO BE PAID $0AA
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Date Paid:. ,t Receipt #: Collected By:
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ved EngineeringNotified of Payment Recei
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REFUND Due: $
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Reconciled Ey. Iy ° Date e�
Copy to: Permit File ❑ Engineering Admin
Revised 2/24/06
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