20050846.pdfDATE RFCEIVEU
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS Ale
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MAILING ADDRESS
CITY ZIP TELEPHONE
NAME
TELEPHONE
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'7 lI PERMIT EXPIRESWERMIT
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NUMBER��� C�
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ADDRESS
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PLAT NAME/SUBDIVISION NO. LOT N LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved O
RW Pem+it Required 0
Street Use Permit Required C3
EXISTING PROPOSED _ Inspection Required 17
Srdirwatk Required 0
REQUIRED DEDICATION FT Underground O
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METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES 0 NOM . z
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REMARKS w
OWNERICONTRACTUR gca O'QN,Dppy7 z
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In addition to the requir`: We
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FIRE REVIEWED BY DATE w
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
•^-`•^�� R9n4+0 sOOMPLETED I EXEMPT
•D Y S NO i
PROPE—RTYYTAX ACCOUNT PARCEL NO.
71 '1:k(=2
❑ NEW RESIDENTIAL PLUMBING / MECH
❑ COMMERCIAL COMPLIANCE OR
❑ ADDITION C❑
❑
MIXED USE CHANGE OF USE
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN
❑❑ GRADING ❑ FENCE X FT.)
REPAIR CYDS
❑ DEMOLISH ❑ TANK ❑ OTHER
FIRE
❑ CARPORT ❑ ROCKERY GARAGE RETAININGWALL ❑ FIREALARM SPRINKLER
(TYPE OF USE, BUST SS O C IVITY EXPLAIN'
1 04 LI
NUMBER NUMBER MF
_ J DWELLING
STORIES (��_ UNITS
IA ' ' 2 HEIGHT
NAI EtL t' USEDFALL WGD PROPOS•ED
5T Y 13
LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
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PARKING LOTAREA ��PLAN��NING REVIEWED BY DATE a
REQ'D I PROy�4� t-'(��1� i E. Li i' !1}o�ail S L'•
TYPE
REQUIRED .n YES
CONSULTANT
OCCUPANT
GROUP
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7 1-t VALUATION
lug 7`< A Description FEE Description FEE
Plan Check State. Surcharge
Hr;AT SOURCE LOf SLOPE% VESTED DATE
Building Permit City Surcharge '"�•
PLAN CHECK NO: Plumbing AWBase Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC ` n.....� ,
E DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIREiii� 11
J SEPARATE PERMISSION. fors oQ3l,i ire
C PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT L LIMIT: SEE BACK OF PINKPERMIT FOR MORE INFORMATIONr44TIT119 __
n9T' r�dtbd► t�](���) Si�ilid,C!i•
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review
L IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
F EDMUNDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
= 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
0 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 APPR VAL
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- CALL Building Official or his/her Deputy: and Foes are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED receipt is acknowledged in space provided
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27. Ay t42C�
GJ 0 1 LS SIG RE DATE
SIG R (O E OR G`E DATE SI kED he
rj, I; / ! 1 -0220 E Y
S=O DATE
ATTENT1014 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, UBC109 I IBC110 I IRC110• PINK -OWNER GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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