20060502 (2).pdfDATE RECEIVED' v
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS /J
MAILING ADDRESS
CITY ZIP TELEPHONE
NAME
4S� /?/ S/6.r/
ADDRESS
;7 549
ZIP TELEPHONE
PERMIT EXPIRES lot jfJiXt1jVK
PERMIT
NUMBER�l)1�
,JOB SUITE/APTn
ADDRESS
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PLAT NAMESUBDIVISION NO, LOT NO. LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TLSCI'Approved ❑
RW' Permd Regdaed ❑
EXISTING _ Street Use I'ernd Hegj1rea 13PROPOSED _._..._._._. _..---.--. 'lnspecuon Hoquaed ❑
Siaewdi+ Regwred ❑
REQUIRED DEDICATION FT Undergrouno ❑
--- Wein re u,rea ❑
METER SIZE LINE SIZE mTO. OF FIXTURES PRV REQUIRED
YES O NO13
REMARKS t7
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE _
W
W
Z
Z
W
CBLN ENGINEERING REVIEWED BY DATE
¢ ADDRESS RECYCLE REVIEWED BY DATE
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rz CITY ZIP f El EPHONE PUBLIC WORKS REVIEWED BY DATE
STATE LICENSE NUMBERREXPIRATION DATE KED BY FIRE RE EWED BY DATE
VARIANCE OR CU SHORELINE OR ADB4 INSPECTION SEPA
-x PROPERTY T A COUNT PA CEL NO.
a REO'D COMPLETED EXEtdPT
j f �a� ' G i OYES ❑ NO
CA# ZONE SIGN AREA HEIGHT
❑ NEW ❑ RESIDENTIAL ❑ PLUMBING / MECH ❑ WAIVER ALLOWED PROPOSED ALLOWED PROPOSED
® COMMERCIAL COMPLIANCE OR [3 STUDY ❑ ADDITION ❑
MIXED USE CHANGE OF USE LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
REMODEL SIGN.
❑ ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
❑ ❑ MULTIFAMILY ❑
❑ REPAIR ❑ GRADING ❑ CYDS ( FENCE X FT.) PARKING LOT AREA PLANNING REVIEWED BY DATE
❑
DEMOLISH TANK
(�p+j OTHER REO'D I PROVIDED ❑ LSI
y ❑GARAGE RETAINING WALL FIRE SPRINKLER REMARKS
CARPORT ❑ ROCKERY Lal FIRE ALARM
0
(TYPE OF USE, BUSINESS O"C�� Y) EXPLAIN:
Uo)
NUMBER NUMBER OF
OF DWELLING
OSTORIES , UNITS $� TYPE OF CONSTRUCTION CODE OCCUPANT
DESCRIBE WORK TO BE DONE% l/
SPECIAL INSPECTION CONSULTANT OCCUPANT
REQUIRED Q YES LOAD
REMARKS
GEOTECH REPORT
BY:
STRUCTURAL DESIGN
BY.
Description FEE Description FEE
HEAT SOURCE LOT SLOPE% VESTED DATE Plan Check ^— State Surcharge
PLAN CHECK NO:n Building Permit L— City Surcharge /
4 5 Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO MBChanIC2I
t BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC
2 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE
I= SEPARATE PERMISSION. Grading
s
w PERMIT APPLICATION: SEE ECDC 19,00,005(A)(5) Engr, Review Recording Fee
a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engf, Ir1SpeCilOn Plan Chk. Deposit
in •APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
Lu IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF Fire Review �Q Receipt #
M EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
a ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
_ FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE Fire Inspection Total Amt. Due �J
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE91
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.• Landscape Insp, Receipt H
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 Ino
THE OWNER, I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- Building Official or his/her Deputy and Fees ate paid. and
TION; AND D HE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION
IN VIOLA ON OF TH OR CODE OF THE STATE OF WASHINGTON RELATING TO receipt is acknowledged in space provided
WORKMEN COMPENSA I INSURANCE AND RCW 16:27, (425) SI URE / DAT
SIGNATURE (VE 4NT): DATE SIGNED 771Y-LOJLGnnO
�•`� �4, •` O ^ ELEASEfJ Y jT
ATTENTIO EXT. 1333 G t
IT IS UNLAWFUL T 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 I IRC1101 ORIGINAL FILE •YELLOW •INSPECTOR
PINK •OWNER •GOLD •ASSESSOR
6/05 PRESS HARD- YOU ARE MAKING 4 COPIES
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