20050644.pdfDATE RECEIVED
CIT OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER. NAME/ M O USIN SS
MAILING ADDRESS
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CITY ZIP TELEPHONE
NAME
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CITY ZIP T L PHONE
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PERMIT EXPIRES
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PLAT`7NAMyEi/,SUABDIVISION NO. r LOT N ID NO.
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET' MAP RMPle
RW Permit Requiqui
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Slrool Use Ponnit Req'd,
EXISTING :::f�PROPOSED Inspection Requirod
� Sidowalk Requirod
REQUIRED DEDICATION '� FT underground
wiring toqulred.
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED t7
ii wtYES C3NO ❑
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REMA z
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE Z
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R CU SHORELINE OR ADB11 INSPECTION BOND I 0
STATE LICENSE NUMBER EXPIRATION DATE CKE BY �� OYES EINO $ O m
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EVIEW SIGN AREA HEIGHTPROPERTY TAX ACCO NT PARCEL NO. EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED -� 'n000 --42�� X �'2-4.5m
NEW RESIDENTIAL PLUMBING / MECH ERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)PROPQSED FRONT SIDEAEAF� FRONT UR SIDE REAR M OADDITION ❑ COMMERCIAL ❑COMPLIANCE OR ��`' {cru 1 �t Cy�J I �r /•7 7 1 r = 0
CHANGE OF USE , r7 O C
PARKING LOT AREA PLANNING REVIEWED BY DATE
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REQ'O PROVIDED
FENCE m .z
❑ REPAIR GRADI G CYDS ❑( X FT) REMAR IC) —'I
OTHER ( D Z
❑ DEMOLISH ❑ TANK ❑ P �q
GARAGE RETAINING WALL FIRE SPRINKLER
Z � CARPORT ❑ ROCKERY ❑ FIRE ALARM
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(TYPE OF USE, BUSINESS OR ACTNITY) EXPLAIN:
2 CH CKED BY TYPE O O RUCTION CO OCCUPANT
GROUP •�
NUMBER NUMBER OF CRITICAL
0OF DWELLING AREAS SPECIAL INSPECTION jPt9EA . OCCUPANT j M m
O STORIES UNITS NUMBER h t I REQUIRED YO
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DESCRIBE WORK TO BE DONE 0 M
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i•� i Description FEE Description FEECn
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Plan Check / '" State Surcharge �� j Z
EAT SOURCE G IN 9` LOT SLOPE % "� O
1rty�,� Building Permit City Surcharge
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PLAN CHECK NO: VESTED DATE Plumbing Base Fee .
Mechanical r
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED: THIS PERMIT COVERS WORK TO
� 100�7 6001
BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC Grading
a DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION,
Engr. Review
W PERMIT APPLICATION: 180 DAYS _
CL PERMIT LIMIT: 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr, Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
rn 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESOR,S Fire Review Plan Chk. Deposit
2 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 N 2(,t
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 lnsp. Total Amt, Due
O NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.•
_ Recording Fee Receipt k 12 OPP'i
'~
1 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. CALLThis 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 aro 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 COMPENSATION INSURANCE AND RCW 18.27.
O IC S SIGNATOR DATE
SIGN ER ENT) DATE SIGNED (425)
i
771=0220 RE BY DAT
ATTEN EXT 1333
IT IS UNLAWFULTO USE OR OCCUPYA BUILDING OR STRUCTURE UNTILA FINAL
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCU ORIGINAL -FILE YELLOW • SP TOR
FANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110. PINK -OWNER GOLD -ASSES OR
09/03 PRESS BARD -YOU ARE MAKING 4 COPIES
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JUL 13 2005
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