20050775.pdfDATE RECEIVEDG
p� rC7 PERMIT EXPIRES J
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CITY OF EDMONDSER V:
CONSTRUCTION PERMIT APPLICATIOSUITEIAPTtt
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OWNER NAMEINAME OF BUSINESS 3 SOME��—
L %Z �� EiSUBDIVISION NO. LO'r NO [.to NO
MAILING ADDRESS G� LID FEE S
m �SLC.r / p GHT OF WAY PER OFFICIAL STREET MAP TESCPApproved�..7v /V L� RW Pormn Required
CITY ZIP TELEPHONE PROPOSED Street Uso Permit Rmtwred
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YES O NO O
ADDRESS
REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
NAME CBL##
ENGINEERING REVIEWED BY DATE
ADDRESS
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CITY ZIP TELEPHONE FIRE REVIEWED BY DATE
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STATE LICENSE NU'MBER n EXPIRATION DATE VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
) A _ /� viclif O� (� � �. - O YESQO NO COMPLETED EXEMPT
PROPERTYJAXACC7NjJ;ARCE NO. CA# ZONE SIGN AREA HEIGHT
,/ WAIVER O - ALLOWED PROPOSED ALLOWED PROPOSED
- STUDY O
❑ NEW RESIDENTIALX%I PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
ADDITION
❑ COMMERCIAL COMPLIANCE OR i
19
13❑ MIXED USE CHANGE OF USE I 1 z
13REMODEL ❑ PARKING LOTAREA PLANNING REVIEWED BY DATE g
❑ MULTIFAMILY SIGN REQ'D PROVIDED
❑❑ GRADING 1:1 FENCE X FT.) REMARKS
REPAIR CYOS
❑ DEMOLISH ❑ TANK ❑ OTHER
❑ FIRE SPRINKCARPORT GARAGE ❑ ROCKERY NING WALL ❑ FIRE ALARM LER
(TYPE OF USE, BUSINESS OR ACTIVIT<z 1I' IN:
TYP QO T U N GROUPANT
NUMBER NUMBER OF '(/
OF DWELLINGI SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES . UNITS REQUIRED YES LOAD
DESCRIBE WORK TO BE DONE
GEOTECH REPORT
BY: I/1 CM
W �'I / �—✓v STRUCTURAL DESIG
BY:
J L�'►� VALUATION
60miSmsrc7r%J toW/ l) b6ff �EP Description FEE Description FEE
t5er OF ,DQN/I✓5T11 IXvJOi✓�-• Plan Check Slate Surcharge
HEAT SOURCE ^/ E
Building Permit City Surcharge
PLAN CHECK NO; Plumbing Base Fee
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
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection RBCBIpI #
< 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 # L71 1
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
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- This application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or hislher Deputy: and Fees are paid, and
IN VIOLATION OF THE LA CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided
WORKMEN'S COMPENS URANCE AND RCW 18:27.
OFFICIALS IGNATURE /DATFISIGNA E (OWNER EN DATE SIGNED (425)7'
L�
771 -0220 ELEAS ATE`/
ATT TION 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-
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 I IBC110 I IRC110. ORIGINAL FILE YELLOW •INSPECTOR
PINK -OWNER •GOLD •ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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