20050764.pdflop
DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWkER NAME/NAME OF WSINE SSt
C L
MAILING ADDRESS
CITYZIP TELEPHONE
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ADDRESS
17j O�j FERMITEXPIRES19-]r' 7
PERMIT
NUMBER
DDRESS " SUITEiAPT#
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP 1ESCPApproved O
RW Permit Required E3
Street Use Permit Requited M
EXISTING PROPOSED Inspection Required O
Sidewalk Requited I'
REQUIRED DEDICATION FT Underground O
Viriting ro used 0
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES O NO O z
z
W
REMARKS W
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
a
z
W
Aj�O / CBL��� w ENGINEERING REVIEWED BY DATE
it: /AADD'DDRESS /s
CITY ZIP TELEPHONE FIRE REVIEWED BY DATE W
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Uj Q4116
r A 44 yo 14 2VI0 414)
STAT (CENSE NUMBER EXPIRATION DATE gy VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
', / NSE U � /1!� `REQ'D COMPLETED EXEMPT
toi79&L / , /.63 2=02 (OAJ RdW�1 V� �1 Q • P(D V G'���Z{ 13 YES NO �4
-J PROPERTYTAXACCOUN PARCEL NO. CA# ZONE SIGN AREA HEIGHT
Q -WAIVER 13 ALLOWED PROPOSED ALLOWED PROPOSED
/ / % / (/ STUDY I, / r • / i/i�l L
❑ NEW ❑ RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REARFRONT UR SIDE REAR t,
❑ ADDITION ❑ COMMERCIAL ❑ COMPLIANCE OR N D lfi ' NO �/� \
❑ MIXED USE CHANGE OF USE _
PARKING LOT AR
REMODEL EA PLANNING REVIEWED BY DATE g
MULTIFAMILY ❑ SIGN [2EOO'D PROVIDED
REPAIR ❑ GRADING ❑ FENCE N
CYDS ( X FT.) REMARKS MO T P 1- I N T•
❑ DEMOLISH ❑ TANK ❑ OTHER
z 1:1GARAGE RETAINING IRE
CARPORT ❑ ROCKERY WALL 1:1FIREALARM SPRINKLER
d (TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
TYPE OFPNS`
TRUCTION CODE OCCUPANT
�j GROUP p .�
w NUMBER NUMBER OF /SCJ f -i
C OF�� DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
j MSTORIES !/ UNITS LOAD
REQUIRED YES
DESCRIBE WORK TO BE DONE
REMARKS O
z
0
:/ `� '✓ ' r ! GEOTECH REPORT m
yoll�% r �BY: � / LL STRUCTURAL DESIGN
/1&> VALUATION
$
Description FEE Description FEE
Plan Check OZ State Surcharge.
HEAT SOURCE LOT SLOPE% VESTED DATE i
Building Permit 21 City Surcharge
PLAN CHECK NO: Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO MBChanICBI
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
M DONMAIN (CURBS,: SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION, Engr. R@VIBW
w PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
a 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
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 �f ��D
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.'
IV
Recording Fee Receipt # 7
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 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 hlSlhor Deputy: and Fees aro pard, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR COD OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged m space provided
WORKM N'S COMPENSATI SU CE AND RCW 18:27. SI URE DATE
GN (OW NT) DATE SI NED (425)
10OX96 771m0220 F*RELtr-A-Dlt
PAT
A ENTIO EXT 1333, k f c
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL " Fit F • VEL OW INSPE OR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC1091 IBC110 I IRC110, PINK • OWNER GOLD - ASSESSOR
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