20050686.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
N ME/NAME OF BUSINESS
77 . / ,J" j I /�1
CITY
NAME
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ADDRESS
7y
CITY
ZIP / I TELEPHONE
ZIP
E
3 PERMIT EXPIRES
PERMIT
NUMBER �l (�`7 V"C -� l/. >
JOB SUITEIAPT#
ADDRESS •�1--�: f.,
PLAT NAMEISUBDIVISION NO. LOT NO LID NO,
LID FEE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Req d C1
RW Permit Required C1
Street Use Permit Required 0
EXISTING PROPOSED Inspection Requited O
Sidewalk Requited 0
REQUIRED DEDICATION FT UndergroundvViiing required �
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES O NOD z
z
w
REMARKS w
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
E5
z
-.,..........� .. �. �.�........ ...� , ty
on fuel -burning appliances passing
through unheated spaces. IMC 803.2
FIRE REVIEWED BY
DATE
NSE NUMBER EXPIRAT ON DATECF)ECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
! REQ'D COMPLETED EXEMPT
L./� / 10YES ONO
TAX ACCOUNT PARCEL NO. CA# ZONE SIGN AREA HEIGHT
❑ NEW
ADDITION
❑ REMODEL
❑
REPAIR
❑
DEMOLISH
GARAGE
❑
CARPORT
(TYPE OF USE, BUSINEE
NUMBER
w
LL
WAIVER iJ ALLOWED PROPOSED ALLOWED PROPOSED
_yam STUDY O t
RESIDENTIAL (/1( PLUMBING ! MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
j�-'� ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
❑ COMMERCIAL COMPLIANCE OR z
❑ MIXED USE ❑ CHANGE OF USE z
PARKING LOT AREA PLANNING REVIEWED BY DATE g
❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED �� ��
❑ GRADING ❑ FENCE
CYDS ( X FT.) REMARKS SE�E/Ery Brf
❑ TANK ❑ CiTy INSPECTOR
OTHER {� �J j
AFFIDAVITS SHAtNOT
RETAININ❑
ROCKERY GWALL FIRE ❑ FIRE ALARM LER RC AflirfrnTFn
NUMBER C
OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES I UNITSLOAD
REQUIRED D YES
DESCRIBE WORK TO BE DONE i
e REMARKS t7
irn addition to the required o
44 AA elmegco�0=14 40`�*� 11 GEOTECH REPORT
BY: ressure/relief valve, an approved :3
-
94fSTRUCTURAL DESI hilted expansion tan shall
BY:
VALUATION ins ed on 8
ll Not watux tanlas$
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Description FEE Description FEE
Plan Check Stale Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit City Surcharge 1✓
PLAN CHECK NO: Plumbing J Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO MBChanIC2I '
BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBIC
i DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION,
E Engr. Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
L PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engf. Inspection
*APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
LNORMLIMIT
NDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
LAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
THE ISSUANCE OF THI&PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE ED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCELandscapeInSp. TOlal Amt. DUe
IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee Receipt04 =OL
#
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
GIVEN IS CORRECT; AND THAT 1 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• CALL Building Official or his/her Deputy: and Fees are paid, and
TION; AND INfiOING THE WORK A I ORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATI OF TH LABOR E OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKME COMPE ATIO RANCE AND RCW 18:27. OFPCIIr I
SIGNAT RE DATE
7,,GURE (OW O DATE IGNE (425)
j AO 7 !•x 1 w0220 RELEASE BY DATE
A TENTION 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 -INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC1091 IBC1101 IRC1100 PINK -OWNER • GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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