20050845.pdfDATE RECEIVED
PERMIT EXPIRES % > `�
CITY OF EDMONDS rPiunRnelER / -.� `;/ /
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CONSTRUCTION PERMIT APPLICATION ADDRESS J�
OWNER NAMEINAME OF BUSINESS cvw Ys�
PLAT NAME/SUBDIVISION NO, LOT NO LID NO
. � r►LO"�. C} .S
MAILING A ESS LID FEE S
7 / �� ZI V M/ S L�/ PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved
I RW Permit Required 0
Street use Pemut Required 0
CITY ZIP TELEPHONE EXISTING PROPOSED Inspection Required O
�•. — Sidewalk Required 17
rc1VK0 nCi S �(yv �V f Z S �' v 3 S`_ REQUIRED DEDICATION FT __ undorground Q
Wum re uuod 0
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES 13 NO is =
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W
ADDRESS REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
z
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NAME % CBL#
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/ F _,,: %j / ENGINEERING REVIEWED BY DATE
ADDRESS
FIRE REVIEWED BY DATE W
CITY ZIP TELEPHONE
LL
STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY VARIANCE OR CU SHORELINE OR ADB# IC C3NSPECTION SEPA
REQ'D COMPLETED EXEMPT
YES 0 NO
CA# ZONE SIGN AREA HEIGHT
PROPERTY TAX ACCOUNT PARCEL NQ.
_ `;,,.a WAIVER 13 ALLOWED PROPOSED ALLOWED PROPOSED
STUDY [3
❑ NEW ❑ RESIDENTIAL PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT L1R SIDE REAR t7
COMMERCIAL COMPLIANCE OR z
❑ ADDITION ❑ CHANGE OF USE z
❑ MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED I
❑❑ GRADING ❑ FENCE
REPAIR CYDS X FT.) REMARKS I
❑ DEMOLISH ❑ TANK ❑ OTHER
❑GARAGE RETAINING FIRE S
CARPORT ❑ ROCKERY WALL ❑ FIREALARMtER
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
-` !� TYP€ OF CONSTRUCTION `CODE OCCUPANT
l=- a GROUP
NUMBER NUMBER OF
OF DWELLINGj SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES Z UNITS /(/ LOAD
DESCRIBE WORK TO BE DONE , f `t r REQUIRED YES
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REMARKS i
1
-IVT f I,GEOTECH REPORT m
BY:
STRUCTURAL DESIGN
BY:
VALUATION
$
�- Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE�7 LOT' SLOPE%VESTED DATE
cs A S Building Permit City Surcharge
PLAN CHECK NO: Plumbing. Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO Mechanical
BE DONEON PRIVATE PROPERTY ONLY: ANY CONSTRUCTION ON THE PUBIC
E DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION.
€ Engr. Review
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PERMIT APPLICATION: SEE ECDC 19.00,005(A)(5)
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 RBVIBW Plan Chk. Deposit
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 #
a ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
r FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE i
3j 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 #
1 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 signod by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL Building Official or his/her Deputy: and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED receiptis acknowled ed In s ace provided.
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION h 9 P
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27, rr
FF ALS SIIGN%T J�2E DATE
SIGNATU A T) DATE SIGNED (4255) s
771 =0220 REL AS BY DAT
ty
ATTENTIOh 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- ORIGINAL .FILE YELLOW -INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC1097 IBC110I IRC110. PINK -OWNER GOLD - ASSESSOR
10104 PRESS HARD m YOU ARE MAKING 4 COPIES
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