20050929.pdfDATE RECEIVED
CITY Of EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
polleir w orld
MAILING ADDRESS
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/� j I PERMIT EXPIRESZL
USE PERMIT
ZONE /• , til ` t.y�_ f l
ti..� NUMBER._ '
JOB SUI E/APTN
ADDRESS r
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PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW PP Approves
RW Permit Required
Street Use Permit Roq'd
EXISTING PROPOSED Inspection Required
CITYO p/ZIP TELEPHONEEXISTINGSidewalk Required p
ZS / 73 U.' / •Z REQUIRED DEDICATION underground
r� 4 E+ Wiring required 13
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED O
YES ❑ NO ❑ z
W
ADDRESS REMARKS z
V OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE c7
Qd W
CITY ZIP TELEPHONE
NAME CBL#
13 GY r;4 IV C0 O q35-3 , ENGINEERING REVIEWED BY DATE
W ADDRESS
FIRE REVIEWED BY DATE WW
CITY ZIP TELEPHONE M
y4sr, 726- k$3S
STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY VARIANCE OR CU SHORELINE OR ADEN INSPECTION BOND
REQ'D POSTED
Aske A . p wA DYES ❑NO 5
✓C r� C O % ��/ ��� $EPA REVIEW SIGN AREA HEIGHT
PROPERTY TAK ACCOUNT PARCEL NO. COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED
00* / 0 0 1 v o Vol EXP ], `J .33.
NEW ❑ RESIDENTIAL 13 PLUMBING I MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR O
COMPLIANCE OR /V
� Z
❑ ADDITION COMMERCIAL ❑ A%1 z
CHANGE OF USE _
PARKING LOT AREA PLANNING REVIEWED BY DATE a
❑ REMODEL ❑ MULTIFAMILY IGN REQ'D PROVIDED /0�3 ✓�
❑ REPAIR ❑ GRADING CYDS •�❑`\(ENCS X FT) REMARKS N
❑ DEMOLISH ❑ TANKGARAGE ❑ OTHER
Z ❑ CARPORT ❑ ROCKIERY NING WALL ❑ FIRE ALARM FIRE INKLER
(TYPE OF USE, BUSINESS O CTNITY) EXPLAIN:
CHECKED BY TYPE OFnSiRrON C E� , OCCUPANT
�i �i✓C GROUP
n NUMBER NUMBER OF CRITICAL
OF DWELLING ZAREAS SPECIAL INSPECTION JAREA OCCUPANT
STORIES UNITS NUMBER REQUIRED YES LOAD
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS PER UBC 108/1FINAL INSPECTION REG'D 9
Description FEEDescription FEE
Plan Check State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %
Building Per � City Surcharge
PLAN CHEC VESTED DATE Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
t BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC Grading
7 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE
SEPARATE PERMISSION,
Engr. Review
us PERMIT APPLICATION: 180 DAYS
d PERMIT LIMIT. 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr, Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
y •APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS ND SUCCESORS Fire Review Plan Chk. Deposit
9 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 #
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE Landscape Insp. Total Amt. Due f
S DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
Recording Fee Receipt #
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• CALLThis 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/tier 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 C IMPENSA _ NCE AN 18.27.
(425) 0 ICI SIGNATURE P9�E
SIGNATURE (OWNI.DATE'SIGNE G F`
jtoll�-�7 771=0220
REL ED BY 14 DATE
ATTENTION EXT 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL f�%117rf(I
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI „ !% ORGINAL •FILE YELL I PECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED, UBC SECTION 109 u� ��{C to 7 PINK • OWNER GOLD -ASSESSOR
04/02 PRESS HARD -YOU ARE MAKI G S OPIES GREEN ACCOUNTING
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