20050834.pdfr
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DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
w MAILING ADDRESS
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CITY\\ ZIP TELEPHONE
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NAME
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TELEPHONE
Z Cj� [PERMIT EXPIRES
P RMIT r �rAirNUMBER%
JOB UITE/APT#
ADDRESS e Ck 5 C/
PLAT NAME/ SUBDIVISION NO. LOT NO, LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved O
RW Permit Required 0
EXISTING PROPOSED Inspereet ction Requi edse Permit equuud O
Sddwa:k Required o
REQUIRED DEDICATION FT Underground [7
----- Weinrequited
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED .
YES D NOD z
W
REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE z
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z
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NAME CBL#
D G 1 0 0 �, ENGINEERING REVIEWED BY DATE
ADDRESS _ _61 600? r 0
5 'rt HONE LLL444 IRE REVIEWED BY DATE it
CITY ZIP TELEP/' it �^
keA-f, WLI `11416��51(_aG3)87afL0k3L3L el.---, LL
STATE LICENSE NUMBER EXPIRATION DATEC CKED BY VARIANCE OR CU SHORELINE OR All B# INSPECTION SEPA
000 REQ'DCOMPLETED EXEMPT
�/� � / D YES ONO
PROPE TY TAXACCOUNT PA(2CEL NO. CA# ZONE SIGN AREA HEIGHT
WAIVER D ALLOWED PROPOSED ALLOWED PROPOSED
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'00611 Z4 i.c STUDY D
❑ NEW ❑ RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SIDE REAR
W.GOMMERCIAL COMPLIANCE OR z
❑
ADDITION ❑ MIXED USE ❑ CHANGE OF USE z
PARKING LOTAREA PLANNING REVIEWED BY DATE
REMODEL g
❑ MULTIFAMILY ❑ SIGN REO'D PROVIDED
❑❑ GRADING ❑ FENCE X FT.) REMARKS
REPAIR CYDS
❑ DEMOLISH ❑ TANK ❑ OTHER
z ❑GARAGE RETAINING WALL FIRE SPRINKLER
CARPORT ❑ ROCKERY L']J FIREALARM
a(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
;:�'�►/r T' TYPE OF CONSTRUCTION CODE OCCUPANT
a�*I�V �V/ (.L� GROUP
c NUMBER NUMBER OF
m OF DWELLING /I SPECIAL INSPECTION CONSULTANT OCCUPANT
O STORIES UNITS (/ LOAD
REQUIRED 1 YES
DES RISE WORK TO BE DONE
Q (• J 3( REMARKS t'
z
0
GEOTECH REPORT
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BY:
STRUCTURAL DESIGN
BY:
VALUATION
Description . FEE Description FEE
Plan Check State Surcharge z_/ 7.)
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit (— City Surcharge
PLAN CHECK NO: Plumbing Base Fee y
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
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
N 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review .l` j Plan Chk. Deposit
LU IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
:E EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection /") ±Receipt #
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLYFROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BEDEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE LandscapeInsp. Amt. Due= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION._Recording Fee ipt # c�
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, 1 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 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 COMPENSATI URANCE AND RCW 16:27,
SIGN U E DATE
SIGNATURE (OWNER OR T)• I DATE
E^SIG ED 7x(425)
7r 1 0220 A/ED BY DATE
ATTENTION EXT. 1333leg
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IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL - FIL . • YELL. W -INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110. PINK -OWNER GOLD - ASSESSOR
10/04 PRESS HARD - YOU ARE MAKING 4 COPIES
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