20051124.pdfDATE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
771
MAILING ADDRESS
CITY ZIP TELEPHONE
P TELEPHONE
CBL#
ADDRESS
PERMIT EXPIRES '
PERMIT � �,� ���
NUMBER
JOB(� ` /1_ ITE APTe
ADDRESS (X1 l/ I/UI'
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TLSCP Approved O
RW Pormd Requded E3
Street Use Perm't Requited 0
EXISTING _ _ __... _ _ PROPOSED ._—..._ .__ Inspection Required O
SideiI Required 0
REQUIRED DEDICATION...-. FT Underground O
yviring ie used O
METER SIZE LINE SIZE NO, OF FIXTURES PRV REQUIRED
YES ❑ , NO ❑
REMARKS r,
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE _
W
W
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" rPC s� r,v :, vent Connectors required W
ENGINE :BY+I :1 ' i ► DATE
>thro.ugh wilizated spaces. IMC 803.2
RECYCL DATE'
CIT ZIP TELEPHONE PUBLIC WORKS REVIEWED BY DATE
s t `' 2t6i (& Z'lz •let)
STATE LICENSE NUMBER EXPIRATION DATE CH EDB FIRE REVIEWED BY DATE W
�lWe Ig IF LL
VARIANCE OR CU SHORELINE OR ADBp INSPECTION SEPA
PROPERTY TAX ACCOUNT PARCEL NO. %�, /') REO'D COMPLETED EXEIAPT
W I o 0 U V lJ ❑YES 0 NO
�/V
CA# ZONE SIGN AREA HEIGHT
.❑ NEW. RESIDENTIAL i� PLUMBING / MECH ❑ WAIVER ALLOWED PROPOSED ALLOWED PROPOSED
77❑�� COMMERCIAL COMPLIANCE OR [3 STUDY
'
❑ ADDITION ❑ CHANGE OF USE LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT)
El MIXED USE ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN
FENCE Z
❑REPAIR z
❑ GRADING CYDS ❑ ( X FT.) P j �,j ♦ ��A lA l�l�j);-Ij ffiWiD BY D TE a
❑ DEMOLISH ❑ TANK ❑
OTHER REO'D 1IIIOOMWIFl77��66�� SS,v C` . G(y�li1l CU
aluep an approved
GARAGE RETAINING WALL FIRE SPRINKLER REMARK ,
Z
❑ CARPORT ❑ ROCKERY ❑ FIREALARM listed e'xyp. nL,r*11on tank shall be
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
installed 6}' 411 hot WBtCY tanks
rc
w NUMBER NUMBER OF "s C`'
m OF DWELLING/ TYPE Q ST T O RCO fy P
o STORIES UNITS [/J' J GROUP
DESCRIBE WORK TO BE DONE
SPE IAL INSPE TION CONSULTANT OCCUPAN
LOAD
1 _ REQUIRED YES
/ REMARKS
GAS
gh• ^y y q -
GAS HIE I ES � WST HE
4 , GE TECH RE ~ L..I VED BY ral I V ITIEFECTUR �
BY: m
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STRUCTURALDESI FA Sell=N01,
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BY , y .
$VALUATION �-
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Description 7Tptlon FEE
G � i2 rchar e
HEAT SO C LOTS PE% VESTED DATE Plan Check gPLA CHECK NO:Building Permitharge
Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO M@ChanIC2I
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION. Grading
t
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr' ReVI@W ReCOrding F@@
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection Plan Chk. Deposit
in "APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
En
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF Fire Review Receipt N
a EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
t ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY Fire Inspection Total Amt. Due 47
x FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE p17
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
x NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.• . Landscape InSp. 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 CALL This application is not a permit until signed by the
I/x\ THE OWNER, I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• INSPECTION Building Official or his/her Deputy, and Fees are paid. and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR eceipt is acknowledged in space provided
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO r
WORKMEN'S COMPENSATION INSURANCE AND RCW 16:27. �4nC\ KFWICRE DATE
SIGNAT E (OWNER OR A N DATE SI NED 771 -GOJn/) ,f]�
✓' i P 6 17 ��r GL RELEAS B �DATE
EXT. 1333
A TENTION
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 / IRC110. PINK • OWNER GOLD ASSESSOR
6105 PRESS HARD- YOU ARE MAKING 4 COPIES
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