20050999.pdfDATE RECEIVED
PERMIT EXPIRES l� i
CITY OF EDMONDS
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CONSTRUCTION PERMIT APPLICATION noDREss SUITEIAPT#
OWNER NAME/NAME OF BUSINESS 9 I J
1 jT PLAT NAME//SSUBDIVISION NO..
LOT NO LID NO
AILING A I S q� o �" t� � LID FEE S
MAILING ADDRESS
i/! , - •. / PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TE SCP Approved
L/ -I ,j /—(. RW Permit Required E3
OILY Street Use Permit Required
ZIP TELEPHONE EXISTING PROPOSED Inspection Required
) (.e Sidewalk Required 0
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REQUIRED DEDICATION FT
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NAM 1 / METER SIZE LINE SIZE NO, OF FIXTURES PRV REQUIRED
1 I cc ( YES NO z
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ADDRE S REMARKS w
OWNNERJCONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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ENGINEERING REVIEW BY DATE.
m0 ADDRESS L 012
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FIRE REVIEWED BY DATE
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STATE LICENSE NUMBER ^EXPIRATION DATE CHECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
t4 REQ'D COMPLETED EXEMPT�+ A S M I "� DYES 0 NO+71, 1, ?4
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a PROPERTY TAXLA�CCOUNT PARCEL NO. CA# DS SZ ZONE SIGN AREA HEIGHT
W �Ql,3Ci+ QD 2. �O� b wnlvER I h / 1 y ALLY PRO SEDLALLOWED PROPOSED
i STUDY O M'7 95 I4.5'
❑ NEW RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SE ACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED �-li SIDE 6AR• FRBIFF k!0
❑ ADDITION ❑ COMMERCIAL ❑ COMPLIANCE OR JS 79 16110 I 1 A(�,
CHANGE OF USE � 9 � Ez
❑ MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g
REMODEL MULTIFAMI�ILY SIGN RLD PROVIDED ElElElFENCE ✓
❑ REPAIRGRA�DI-N�Cy ❑ ( X FT.) REMARKS
❑ DEMOLISH ❑ TANK
❑ OTHER
ARAGE ❑ RETAINING WALL ❑ FIRE SPRINKLER
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(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
TYPE OFtOMTRUCTION CODE OCCUPANT
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WA NUMBER NUMBER OF
O OF { DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
O STORIES j UNITS LOAD
REQUIRED 0 YES .
DESCRIBE WORK TO BE DONE
REMARKS 0
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GEOTECH REPORT
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Description FEE Description FEE
Plan Check 46V State Surcharge 5-0
HEAT SOURCE LOT SLOPE% =ESTED DATE
Building Permit �70 City Surcharge
PLAN CHECK NO: t" Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
C BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
Grading
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
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Engr. Review Q
to PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
IL PERMIT LIMIT: SEE ECDC 19,00,005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
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•APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection ReceiptALL 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 LandscapeInsp. Total Amt. Due rNOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.' /-
Recording Fee Receipt # 191561
7
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 This application is not a permit until signed by the
THE OWNER, 1 AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC•
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or hIs/hor Deputy: and Foes 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 TION INSURANCE AND RCW 16:27,
0 CI S SIGNAT E DATE
SCAT URER AGENT): DATE SI NED (425)
-�- �� O� 771 -0220 REL SED BY / AT�
WN
J61
ATTENTION EXT. 1333 D�
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL bg
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FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109If IBC1101 IRC110, PINK -OWNER GOLD - ASSESSOR
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