20050720.pdfAnDATE RECEI ,�•-
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PERMIT � _
CITY OF EDMQNDS NUMBER ,` . ,`� w
CONSTRUCTION PERMIT APPLICATION noDREss SUITEIAPT#
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OWNER NAME/NAM[OF�BUSINESS
v }� r PLAT NAMEISUB DIVISION NO. LOT NO ID NO.
W MAILING ADDRESS 1 �./ LID FEE $
/ TESCP Approved E3
b PUBLIC RIGHT OF WAY PER OFFICIAL STREET' MAP
O - 0 RW Perm
n Regwred
CITY _ Street Oso Pormn Required 3
ZIIIP` TELEPHONE EXISTING PROPOSED Inspection Required O
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Sidewalk Rmiurted O
ti ��t✓ REQUIRED DEDICATION FT under round O
Wifinq required
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES O NO O 9
I_ ADDRESS REMARKS w
UOWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE u
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CITY 'LIP TELEPHONE409
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NAME CBL#
ENGINEERING REVIEWED BY DATE
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O CITY 21P TELEPHONE
STATE LICENSE NUMBER EXPIRATION DATE NECKED Y RIANCE O U ORELINE OR ADB# INSPECTION' SEPA
RE,O'D COMPLETED I EXEMPT
O YES .O NO
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� PROPERTY TAX ACCOU TPARCELNO. CA# ZONE SIGN AREA HEIGHT
dc � WAIVER O ALLOWED PROPOSED ALLOWED PROPOSED
STUDY O
❑ NEW ❑ RESIDENTIAL❑ PLUMBING / MELOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
9 COMMERCIAL COMPLIANCE OR ?
❑ ADDITION ❑CHANGE OF USE i
❑ MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g
❑ REMODEL ElMULTIFAMILY ❑ SIGN REQ'D PROVIDED
❑ REPAIR ❑ GRADING CYDS ❑ FENCE X FT.i REMARKS
❑ DEMOLISH ❑ TANK iia 0T11ER
L�1r,; fP✓ G 1h A !Xf r
FIRE
_ ❑ CARPORT ❑ ROCKERY RAGE RETAININGWALL ❑ FIREALARM SPRINKLER
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a (TYPE OF USE,•BUSINESS OR ACTIVITY) EXPLAIN:
TYPV 3F.00NSTRUCTI kO E OCCUPANT
A1C Ii�Q V� f�t a GROUP
U
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o NUMBER NUMBER OF
OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
O STORIES UNITS �� LOAD
REQUIRED Q YES
DESCRIBE WORK TO BE DONE
O S r t! REMARKS z
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e S Y\ Y 1 U GEOTECH REPORT
BY: m
STRUCTURAL DESIGN
BY:
VALUATION
Description FEE Description FEE
Plan Check r_ State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE v
Building Permit \ City Surcharge t
PLAN CHECK NO: Plumbing
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. iiHIS PERMIT COVERS WORK TO Mechanical
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
t SEPARATE PERMISSION,
Engr. Review
w PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
IL PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection ~
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
*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
EDMONDS, WASHINGTON• ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection —" Receipt #
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
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee Receipt #
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
GIVEN 15 CORRECT; AND THAT I 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-
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or hislhor Deputy: and Fens 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 CO SATION INSURANCE AND RCW 18:27.
FI LS SIG RE DATE
S71AURE WN R R AGENT): DATE SIGNED (425)V/0
w 1 �_S 7710220 L A Y / DAT
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 CERTI- ORIGINAL . FILE YELLOW • INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC1091 IBC110 I IRC1100 PINK -OWNER GOLD ASSESSOR
10104 PRESS HARD = YOU ARE MAKING 4 COPIES
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