20050816.pdf/� r DATE RECEIVED
r �/ PERMIT EXPIRES
USE PERMIT
CITY OF EDMONDS ZONE NUMBER/ ' /``�r/� ?
CONSTRUCTION PERMIT APPLICATION JOB SUITE/APT#
AOURESS . •� / 6 _y '�•
OWNER NAME/NAME OF BUSINESS Z.3 Z l
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C� f< C� 6 /2 / PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
UM MAILING ADDRESS LID FEE S
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d PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP AW Pe Approved Q
StreetUse Pert
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CITY fzlP TELEPHONE EXISTING PROPOSED Inspection Required Q
Sldnwalk Required Q
REQUIRED DEDICATION Fr Underground
Eaw O4 '� p Wising required Q
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES ❑ NO ❑ z
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ADDRESS REMARKS z
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= OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE 2
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CITY ZIP TELEPHONE
NAMEEJ CBL# -
N 40` ENGINEERING REVIEWED BY DATE
C ADDRESS
CITY O O 4 r,,It ZIP TELEPHONE FIRE REVIEWED BY DATE Q
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19 Z O 3 2Y - %7.7 Q O �,7~ VARIANCE OR CU SHORELINE OR ADB# INSPECTION BOND
STATE LICENSE NUMBER E IIR/}TION DATE . C •CKEO BY REO'D POSTED
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OYES ENO $
�Z SEPA REVIEW SIGN AREA HEIGHT
PROPE TY A COUNT PA CEL O. COMPLETE EXEMPT ALLOWE PROPOSED ALLOWED PROPOSED
EXP X `i-Z� 3'-I-• 5� elder t b ld�
NEW ❑ RESIDENTIAL ❑ PLUMBING l MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
OL�ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SIDE REAR
❑ADDITION COMMERCIAL COMPLIANCE OR f — A 1 z
. ❑ CHANGE OF USE N/G 1 v z
PARKINGLOT AREA PLANNING REVIEWED BY DATE 5
❑ REMODEL ❑ MULTIFAMILY (�GN REQ'D PROVIDED /• -:F ^ '_ f a
❑ REPAIR ❑ GRADING CYDS ❑ FENCE
( X FT) REMARKS Q „ I^ ��
❑ DEMOLISH ❑ TANK ❑ OTHER BMJ /� ��
GARAGE RETAINING WALL FIRE SPRINKLER w
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C ❑ CARPORT ❑ ROCKERY ❑ FIRE ALARM 1. , /� n n o , �-- R ry A . f bye VAD P��
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN: , v wuw w "1 : / Y
CHECKED BY TYPE OF NST UCTION07 CCS OCCUPANT
oe - :1 / \ J GROUP
G NUMBER NUMBER OF CRITICAL V
OF ' DWELLING %�� AREAS n J SPECIAL INSPECTION JAREA OCCUPANT
O STORIES UNITS ! T NUMBER ! �/ REQUIRED ❑YES LOAD
DESCRIBE WORK TO BE DONE
REMARKS z
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REVD 9
m
VALUATION
$
Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %
Building Permit City Surcharge
PLAN CHECK NO eo7ry7 VESTED DATE Plumbing.
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Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
� Engr. Review
PERMIT APPLICATION: 180 DAYS
IL PERMIT LIMIT. 7 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr, Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS 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 Receipt N
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE
9 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due y
C NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
_ Recording Fee Receipt N '
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- CALL This application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED Building Official or his/her Deputy: and Fees are 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 COMPENSAT URANCE D RCW 18.27.
0 ICI S SIGNATOR DTE
SIGNATURE (OWNER N DATE SIGNED . (425)
771n0220 R D Y TE `
A NTI N EXT 1333
ITIS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORlcl AL •FILE ELLOW • IN PECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED, UBC SECTION 109 PINK - OWNER GOLD -ASSESSOR
04/02 PRESS HARD =YOU ARE MAKING 5 COPIES GREEN• ACCOUNTING
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