20050772.pdfDATE RECEIVED
- jv PERMIT EXPIRES 14NOW11A
CIT EDMONDS NUM�IER t0> -0
CONSTRUCTION PERMIT APPLICATIONJOB SUITE/APT#
ADDRES
OWNER NAMEINAME OF BUSINESS �L
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3 I� PUBLIC RIGHT WAY PER OFFICIAL STREET MAP TESCPApproved Q
O _ '- ,� .� r. �� � ('�'� r / RW Permit Required Q
CI I [�(/j/.f'�.• j/1'�/. _ _ Street Use Permit Required
iEXISTNG PROPOSED Inspgcuon Requug9TELEPN
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Sidewalk Required Q
' REQUIRED DEDICATION FT Ondarground Q
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Wirinq required Q
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
�^ (.) YES la NO 1:1 z
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t ADDRESS REMARKS W
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CITY ZIP ITELEPHONE
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NAME CBL#
1 Re it /0""r t ENGINEERING REVIEWED BY DATE
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FIRE REVIEWED BY DATE
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
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REI (� .1u.1 OLI I V O YES 0 NO
PROPERTY TAX ACCOUNT PARCEL NO. CA# ZONE SIGN AREA HE
Lail WAIVER O ALLOWED PROPOSED ALLOWED PROPOSED
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❑ NEW ❑ RESIDENTIAL � PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SIDE REAR
IN
COMMERCIAL COMPLIANCE OR ?
❑ ADDITION ❑ MIXED USE ❑ CHANGE OF USE i
REMODEL ❑ PARKING LOT AREA PLANNING REVIEWED BY DATE
REQ'S
MULTIFAMILY ❑ SIGN D PROVIDED
❑ REPAIR ❑ GRADING ❑ 61
FENCE
CYDS X FT.) REMARKS
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❑ DEMOLISH ❑ TANK ❑ OTHER
GARAGE Z ❑ CARPORT ❑ ROCKERY IG WALL FIRE ❑ FIRE ALARM SPRINKLER
a (TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
TYPE OF CONSTRUCTION OCCUPANT
' CODE ,
GROUP
w NUMBER' NUMBER OF
O OF s'� DWELLING \ SPECIAL INSPECTION CONSULTANT OCCUPANT-
! O STORIES UNITREQUIRES LOAD
7 D YES
DESCRIBE WORK TO BE DONE Q
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4 rct t %INS VALUATION
1 -It k.J eLx1AAIA Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit City Surcharge
PLAN CHECK NO:
r �• Plumbing. Base Fee r
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS 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)
a 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
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IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
i EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
Q 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 t
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION .• r
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 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 nowl Deputy: and Foes are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt Is acknowledged n space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27,
OFFICIALS SIGNATURE DATE
SIGNAT - OWNER AGE ): DATE SIGNED (425)
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/a_r 771 w022O RELEASED BY i LATE rATTENTION EXT. 1333IT 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 INSPECII R
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC1101 IRC1100 PINK -OWNER GOLD - ASSESSOR
110104 PRESS HARD - YOU ARE MAKING 4 COPIES
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