20051166.pdfDATE RECEIVED 12
CITY OF EDMONDS
C NSTRUCTION PERMIT APPLICATION
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NAME
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CITY ZIP ITELEPHONE
NAME BL #
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY
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PROPERTY TAX ACCOUNT PARCEL NO.
105 [�PERMITEXPIRES
USE PERMIT
ZONE NUMBER 70oi;-
JOB SUITE/APT#
ADDRESS
PLAT NAM E/S UBDIVI SION NO. LOT NO. LID NO.
PUBLIC R I GHT
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REMARKS z
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE 5
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ENGINEERING REVIEWED BY DATE
FIRE R or vent connet:Liu, b 1 r-4vA
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7 2ppliances passing
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SEPA REVI EW SIGN AREA HEIGHT
COMPLETE , EXEMPT ALLOWED , PROPOSED, ALLOWED I PROPOSED
0 LOT COVERAGE REQUIRED SETBACKS (FT) PROPOSED SETBACKS (Fr.)
13 NEW RESIDENTIAL PLUMBIN C/ME�C2 ALLOWED PROPOSED FRONT SIDE REAR FRONT L/RSIDE REAR
COM PLIANCE OR
11 ADDITION COMMERCIAL
El DCHANGE OF USE
PARKING LOT AREA PLANNING REVIEWED BY DATE
06
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REMODEL
REPAIR
DEMOLISH
GARAGE
CARPORT
U MULTIFAMILY
GRADING
CYDS
TANK
RETAINING WALL
13 ROCKERY
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SIGN
FENCE
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OTHER
FIRE SPRINKLER
FIRE ALARM
REO'D
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REMARKS
rrVPE OF USE BUSINESS OR A IVrrA EXPLAIN:
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CHECKED BY
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GROUP
NUMBER
M OF
STORIES
NUMBER OF
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UNITS I
CRITICAL
'T'C'
TAREAS
AREAS
NUMBER
UMB
SPECIAL INSPECTION
REQUIRED [] YES
JAREA
OCCUPANT
LOAD
DESCRIBE WORK TO BE DONE
REMARKS z
PROGRESS INSPECTIONS PER UBC 1081IBC109/[RC109 FINALINSPECTION REO'D
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VALUATION
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Description
FEE
Description
FEE
55 �'QAw L�
Plan Check
State Surcharge
HEAT UR E GLAZINQ %
LOT SLOPE %
Building Permit
City Surcharge
Base Fee
PLAN CHECK NO:
:D DATE
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
a DOMAIN (CURBS, SIDEWALKS. DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
:3
SEPARATE PERMISSION.
Engr. Review
ul PERMIT APPILICATION: 180 DAYS
06 PERMIT LIMIr I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
ffiAPPLICANT. 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
2 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 PE13MIT SHALL NOT 13E
Landscape Insp.
Total Amt. Due
00
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE C17YS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
Recording Fee
Receipt N
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
THE OWNER. I AGREE TO COMPLY WITH CiTY AND STATE LAWS REGULATING CONSTRLIC-
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 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 COMPENSATION INSURANCE AND RCW 18.27.
OF I IALS N RE DATE
SIG URE (OWNER C AGLEa
DATE SIGNED
(425)
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A X0 da,
I L lag, La�;—
771-0220
IRELE
I DATE
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ATTENTION
EXT 1333
IT IS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE AND APPROVALOR A CERTIFICATE OF OCCU-
ORIGINAL - FILE - YELLOW - INSPECTOR
PANCY HAS BEEN GRANTED. UBC109/IBC110/iRC110.
PINK -OWNER GOLD -ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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