20060453.pdfr DATE RECEIVED,, �
PERMIT EXPIRES .
CITY OF EDMONDS NUMBIER / - Lir
CONSTRUCTION PERMIT APPLICATION noDHEss UITEiAPTa
OWN R NAME/NAME OFF BUSINESS I r (/, /
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
MAILING ADDRESS / l c
W LID FEE
O ) s / C I PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TLSCP Appmven 0
RSY Perms Heqi.red 0
Seem Use Permpt Required 0
CITY ZIP TELEPHONE EXISTING _ PROPOSED _ __________ .__ InspeChen Required 0
Soewau Reqwred 0
�� REQUIRED DEDICATION _ FT underground 0
Worinq re weed 0
NAME r� {, ; METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES[3 NO ❑
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ADDRESS REMARKS 0
u ,� OWNER;CONTRACTOR RESPONSIBLE FOR EROSION CONTROU•DRAINAGE
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CIT F ZIP TELEPHONE z
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NAME C CBL# ENGINEERING REVIEWED BY DATE
4I% C J J In Y
M ADDRESS RECYCLE REVIEWED BY DATE
R 1016
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CITYZIP TELEPHONE PUBLIC WORKS REVIEWED BY DATE
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STATE LICENSE NUMBER EX IRATION DATE CH KED BY FIRE REVIE ED BY DATE w
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VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
Q PROPERTY TAX ACCOUNT PARCEL NO.
REQ'D COMPLETED EXEMPT
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❑ YES ❑ NO
CA# ZONE SIGN AREA HEIGHT
❑ NEW ❑ RESIDENTIAL ❑ PLUMBING / MECH ❑ WAIVER ALLOWED PROPOSED ALLOWED PROPOSED
❑ADDITION *COMMERCIAL COMPLIANCE OR ❑ STUDY
❑ CHANGE OF USE LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
❑
❑ MIXED USE ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR REMODEL ❑ MULTIFAMILY ❑ SIGNI M2
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❑ REPAIR ❑ GRADING CYDS ❑ FENCE
( X F1'.) PARKING LOTAREA PLANNING REVIEWED BY DATE Ja
❑
OTHER REQ'D I PROVIDED DEMOLISH ❑ TANK ❑
❑GARAGE RETAINING ❑ WALL FIRE SPRINKLER REMARKS
z CARPORT ROCKERY
a(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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c NUMBER NUMBER OF
m OF DWELLING TYPE OFCONSTRUCTIO CODE OCCUPANT ,
p STORIES - UNITS - %% - GROUP L
DESCRIBE WOR E DONE 1/
SPECIAL I PECTION ` CONSULTANT OCCUPANT
LOAD
j REOUIRED YES
dit, 5A! 1 Te 1 t - 1 i. REMARKS
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GEOTECH REPORT m
2 BY. .
STRUCTURAL DESIGN
BY
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Description FEE Description FEE .
HEAT SOURCE LOT SLOPE96 VESTED DATE Plan Check40 T State Surcharge
PLAN CHECK N0: _ Building Permit City Surcharge
PLAN CHECK NO: z
-' Plumbing Base Fee 75 ...
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO MBChanIC81
t BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC,
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
t SEPARATE PERMISSION, Grading
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
Lu PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Review Recording Fee
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engr, Inspection Plan Chk. Deposit i
ti •APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
w IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF Fire Review — Receipt ri La
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY Fire Inspection �— Total Amt. Due L
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE p
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.' Landscape Insp. Receipt01
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 pem, until signed by the
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THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- 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 INSPECTION receipt is acknowledged In space provided
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27. (425) KY/
DATE
RE( N R AGENT): DATE SIGNED 6J J 71 1 , i
L Cs ( 771 -0220 RE DATE
EXT. 1333
ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110. ORIGINAL • OWNER FIL
•YELLOW -INSPECTOR
PINK -R •GOLD -ASSESSOR
6/05 PRESS HARD - YOU ARE MAKING 4 COPIES
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