20051070.pdfDATE RECEIVED
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1 Z S PERMIT EXPIRESI E
CITY OF EDMONDS NUMBIER
CONSTRUCTION PERMIT APPLICATION JOB SUITE/APT#
ADDRESS '/ /Aft
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OWNER NAMEMAME OF BUSINESS VV !1 / V tt t
JA1 j `� F' j L�j) ��,•Of I /� PLAT NAME/SUBDIVISION NO. LOT NO. LID N0.
K MAILING ADDRESS 1/ /`� /[ bV LID FEE 5
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�% !) / PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPAppravod ❑
I v �%ry RW Permit RZed ❑
Street use Permit Required ❑
CITY ZIP TELEPHONE EXISTING PROPOSED inspection Requited ❑
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bPION as wA ��8z - a� �:� (,j �G` REQUIRED DEC
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STATE LICENSE NUMBER EXPIRATION DATE C K D BY VARIANCE IR CU SHORELINE OR ADB# INSPECTION SEPA
REO'D COMPLETED EXEh1PT
C(1 C (! L U IO O 7 NO
PROPERTY TAX ACCOU T PAR - NO: CAN ZONE j' HEIGHT
0 WAIVER I� j 1' IcT @
O ♦/ STUDY f] f >1 V V ` �LL04ED J� GRED, PROPOSED
❑ NEW RESIDENTIAL ❑ . PLUMBING I MECH LOT COVERAGE: r tr fit
EQ !!D 5 A (F ti1 I'R E ETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR t7
❑ COMMERCIAL COMPLIANCE OR =
❑ ADDITION" ❑ MIXED USE ❑ CHANGE OF USE z
❑ PARKING LOT AREA PLANNING REVIEWED BY DATE
❑REMODEL g
MULTIFAMILY ❑ SIGN REQ'D, PROVIDED
1:1 REPAIR ❑ FENCE X FT.) REMARKS
REPAIR CYUS
❑ DEMOLISH TANK ❑ OTHER
GARAGE _ ❑
CARPORT ❑ ROCKERY NING WALL ❑ FIREA ARM IRE LER
1. (TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
0.L TANK � 'CC' m m 1 ss i0 A1y TAYEDF CONSTR ON OC�BE GOCCUPAJ
ROUP N K
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GNUMBER NUMBER OF
OF. DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
p STORIES - UNITS LOAD
REQUIRED 0 YES
DESCRIBE WORK TO BE DONE
REMARKS z
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C ,V GEOTECH REPORT m
• ( BY:
• E3J) �R/L' G %`/ P STRUCTURAL DESIGN
BY:
AA Ci VALUATION
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i i- til bQ 1 r Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCEa"a LOT SLOPE% VESTED DATE '
Building Permit City Surcharge
PLAN CHECK NO: Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO Mechanical
I= BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBIC
M DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
J SEPARATE PERMISSION.
w PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5) Engr. Review
a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION EngL Inspection
'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 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 #
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. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL Building Official or hislhor 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 1nowledged In space provided.
WORKMEN' ENSATION INSURANCE AND RCW 18:27,
OFFIL SIGNA UR' DAT
(OWNER AGEN DATE SIGNED (425'
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771 -0220 RELEAS DBY DATE
ATTENTION 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 if IRC1104 PINK .OWNER GOLD ASSESSOR
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