20050961.pdfDATE RECEIVED
[PERMIT EXPIRES
CITY OF EDMONDS NUBER 002C�C�tS %
CONSTRUCTION PERMIT APPLICATION oDRESS {� I �Li(U�' t-WL1 SUITEIAPT#
OWNER NAMEINAME OF BUSINESS /� � ` Api d � C`{ &021 0
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W �� PLAT NAM EIS BDIVISION N0. LOT NO LID NO
K MAILINGADDRESS lJ V (`/ t -+ l C� LID FEE S
Cj C i J� PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApproved O
O yl (000 qlt) r 1 t yLj. l-s� RW Permit Required
Street use Permit Required
CITY
ZIP TELEPHONE EXISTING ^___ PROPOSED _ Inspection Required 17
11 14, 2C 37 _— Sefe rgrcalk Required 0
S REQUIRED DEDICATION FT
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NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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I= ADDRESS REMARKS W
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STATE LICENSE NUMBER EXPIRATION DATE ECKED BY ARIANCE O U SH ELINE OR ADB# INSPECTION SE
READ COMPLETED EXEMPT
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PROPERTY TAX ACCOUNT PARCEL NO. CA# ZONE I SIGN AREA HEIGHT
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❑ NEW ❑ RESIDENTIAL ❑ PLUMBING I MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR r,
GrCOMMERCIAL COMPLIANCE OR z
❑ ADDITION ❑ CHANGE OF USE Z
❑ MIXED USE PARKING LOTAREA PLANNING REVIEWED BY DATE g
REMODEL ❑ . MULTIFAMILY 1:1SIGN REO'D PROVIDED
❑,❑ GRADING ❑ FENCE
REPAIRX FT.) REMARKS
CYDS ( _
❑ DEMOLISH ❑ TANK. 1:1OTHER
GARAGE Z ❑ CARPORT ❑ ROCKERY IG WALL [3FIREALARMFIRE KLER
(TYPOF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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I OF DWELLING .� SPECIAL INSPECTION CONSULTANT OCCUPANT 0 let
O STORIES UNITS
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DESCRIBE WORK TO BE DONE
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STRUCTURAL DESIGN
BY:
`} VALUATION
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' Description FEE Description FEE
Plan Check IN State Surcharge
HEAT SOURCE `1 LOT SLOPE% VESTED DATE
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` IVd 01Building Permit City Surcharge
PLAN CHE'G NO: Plumbing Base Fee .�
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO MBChanIC81
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BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC Gradin
J DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, .MARQUEES, ETC.) WILL REQUIRE g
t SEPARATE PERMISSION.
Engr. Review
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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
U) *APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
LU IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
: 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
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 # Q
I HEREBY ACKNOWLEDGE THAT 1 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 signed by the
THE OWNER. 1 AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• CALLBuilding Official or his/her Deputy! and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S COMP NSATION INSURANCE AND RCW 16:27.
O IC � SIGN URE DATE
S( ATU (041:�TIi.1 L&�u DATE SIG ED / (425)
dl `,� 771 -0220 RELEASED BY DTE
ATTENTI EXT. 1333�ll�(%�
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, UBC1091 IBC1101 IRC110. PINK -OWNER GOLD - ASSESSOR
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