20051021.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAM OF BUSINESS
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MAILING ADDRESS
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CITY ZIP TELEPHONE �715; 7�jQ
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NAME
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ADDREESSSS
CITY
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NAME iBl.a
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ADDRESS
PERMIT EXPIRES L -�
USE PERMIT
ZONE NUMBER
JOB _ SUITE/APT#
ADDRESS
PLAT NAME/SUBDIVISION NO. LOTw6. LID NO.
LID FEE S
CP
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW
Pe Approved 0
W rme Required O
Street Use Permit Roq'd (3
EXISTING PROPOSED inspection Required )'
Sidewalk Raquirod El
REQUIRED DEDICATION FT Undergrormd
Wiring roqutrod O
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED 47
YES ❑ NO ❑
REMARKS z
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE a
REVIEWED BY IDATE
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CITY ZIP TELEPHONE 9E
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TATE LICENSE NUMBER EXPIRATION DATE C BY VARIANCE OR CU SHORELINE OR ADBq INSPECTION BOND
REQ'D POSTED
10YES $
CH SEPA REVIEW SIGN AREA HEIGHT
PROPERTY TAX ACCOU PARCEL NO. COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED
AF 42 C)50Fc7SM �� EXP
NEW RESIDENTIAL❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (IT) ❑ ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR]
ADDITION ❑ COMMERCIAL ❑ COMPLIANCE OR n �O /� Misr f. I'JS / / z
CHANGE OF USE �C! y� Gr ( z
❑REMODEL MULTIFAMILY PARKING LOT AREA PLANNING REVIEWED BY DATE a
' ❑ ❑ SIGN REQ'D PROVIDED �w �J.
1:1❑GRMG ❑ FENCE X FT) REMARKS
REPAIR CYDS
❑ DEMOLISH ❑ TAN ❑ OTHER
❑ GARAGE CARPORT ❑ ROCKERY WALL FIRE ❑ FIRE ALARM LER
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN: I SEEN
CHECKED BY TYPE OFC N UCTION CQaE OCCUPAN
rGROUP
NUMBER NUMBER OF CRITICAL
OF DWELLING AREAS SPECIAL INSPECTION AR IL A J
EA OCCUPANT
O STORIES UNITS 1t1 NUMBER REQUIRED ❑ YES I LOAD
DESCRIBE WORK TO BE DONE
REMARKS i
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PR OGRESS INSPECTIONS PER UBC 108/IBC109/IRC109FINAL INSPECTION REO'D 9 GLD�� X12 � . � . p 1�1
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N O F -A -M IL`( SOD VALUATION
APD MAP$
�d D i✓ �,�L Description FEE Description FEE
Plan Check -� State Surcharge
HEAT SOURCE GLAZING % LOTS O %
2 0 AV P� � n Building Per � f � City Surcharge
PLAN CHECK NO•) VESTED DATE Plumbing Base Fee f
G
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY, CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION.
a Engr. Review
W PERMIT APPLICATION: 180 DAYS
CL PERMIT LIMIT. 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS Fire Review 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 #
Q ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY Cl 10) 11
= FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
S DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due
= NOR LIMIT IN ANY WAY THE CITYs ABILITY TO ENFORCE ANY ORDINANCE PROVISION'
Recording Fee Receipt # pc? Lj
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
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL This 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/her 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 COMPENSATION INSURANCE AND RCW 18.27.
F C LS SIGNATU E DATE
SIGNA U (OWN R O AGE nDATE SIG ED 1 (425) ; 2
(f <g' 10b5
771 -022 RE SEU BY L ATE
ATTENTION EXT 1333
ITIS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL I `7
INSPECTION HAS BEEN MADE AND APPROVALOR A CERTIFICATE OF OCCU
ORIGINAL •FILE YELLOW •INS CTOR
PANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110. PINK -OWNER GOLD • ASSESS^r'
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