820514.pdffill
us PERMIT
CITY OF EDMONDS ZONE NUMBER 1 Z
h?U51 �
CONSTRUCTION PERMIT APPLICATION ,Qt,
j NAME ;OR NAME OF BUSINESS) 1 ADORES'' IO..I 4 0LY/M`11 C-
�.._• _ t /1. `� /�� /y/ /7 LEGAI f1ESCNIITIWN Cr1ECx SIIDDIVISION NO V LID NO
Z MAILING ADDRESS
CITY IELEPNONE N UM B/E R PUBLIC i11G11T OF WAY PER OFFICIAL STREET MAP
��'/CI I�/�,/ 17 LI �-/ ')� , EXIST ING REQUIRED DEDICATION
PROPOSED
NAME
RIGHT OF WAY CONSTRUCTION PERMIT REQUIRED
ADDRESS STREET USE PERMIT REQUIRED
= SEE ENGINEERING MEMO DATED
CITY TELEPHONE NUMBER SEE PIW DEPT REVIEW CHECK LIST DATED
REMARKS
NAME
SIZE IBUILDING SUPPLY SIZE
GATE LICENSE NUMBER CITY LICENSE NUMBER
I
SIGN AREA ENV REVIEW AOB NO.
Description of Property - Include all easements
ALLOWED PROPOSED COMPLETE EXEMPT
A_egal
show below or attach four copies)
i\ / SHORELIN 1'
VARIANCE OR CU PLANNING REVIEW BY DATE
YARDS N / A LOT COVERAGE
FRONT SIDE REAR
REMARKS
GI kIMirAe c+��c,kusT t7ATeD 17-
10. El
�
EW RESIDENTIAL
PLUMBING
OADD/ALTER
NON-RESIDENTIAL
MECHANICAL
El
El
REPAIR RETAINING WALL
SIGN
EXCAVATE
DEMOLISH OR FILL
FENCE
1--x__Fn
CHECKED BY TYPE OF CONSTRUCTION LODE -T HEIGHT
,
�- N , 1 1
❑PRE'MOVE INSP.I
❑ SWIM
SPECIAL INSPECTOR AREA OCCUPANCY OCCUPANT
COMPLIANCE INSP.
L
REQUIRED GROUP ^ -� LOAD
: YES NO K
❑ SIDE SEWER 1:1WATER LINE
REMARKS
17TALL. peX?_ MFRIZ S t-
NUMBER OF STORIES NUMBEROF
Ll CAbL e C copE-S
DWELLING
UNITS
NATURE OF WORK TO BE DONE (ATTACH PLOT PLANT
f Iy��)LESS Ibis PCB-'�'�or,lS �"'FV
Z.✓j 14GL 2 /1CIJ
9LIZ Nl Vei
Jai/ 4 G I- /N j 4-g T
VALUATION FEE
PLAN CHECK FEE
BUILDING
/
PLUMBING
/
MECHANICAL
00
,
This Permit covers work to be done on private property ONLY. GRADINGIFILL
/
Any construction on the public domain (curbs, sidewalks,
driveways, marquees, etc.) will require separate permission.
Permit Application: 180 Days
Permit Limit: 1 Year - Provided Work Is Started Within 180 Days
"Applicant, on behalf of his or her spouse, heirs, assigns and
ui successors In interest, agrees to indemnify, defend and hold
w harmless the City of Edmonds, Washington, Its officials,
aemployees • and agents from any and 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
0
modify, waive or reduce any requirement of any city ordinance
nor 11mil In any way the City's ability to enforce any ordinance TOTAL AMOUNT DUE
/- 294Q
provision.,.
((/. �-
1 hereby acknowledge that I have read this application; that the
Information given Is correct; and that I am the owner, or the duly ATTENTION
APPLICATION APPROVAL
authorized agent of the owner. I agree to comply with city and THIS PERMIT
slate laws regulating construction; and in doing the work authoriz• AUTHORIZES
This application Is not a permit until
ed thereby, no person will be employed In violation of the Labor ONLY THE
signed by the Building Official or his
Code of the State of Washington relating to Workmen's Compensa•. WORK NOTED
Deputy; and fees are paid, and receipt Is
ti n Iggyroinca. INSPECTION
acknowledged in space provided.
fiA (OWNER O AGEN � D Tf' S DEPARTMENT
rIg
CITY OF
OFFICIAL'S SIGNATURE
EDMONDS
1 anpPcC �},K�
THIS SITE IS LOCATED IN THE CITY
OF EDMONDS, LOCAL SALES TAX 775 2525
DATE
ATTENTION SHOULD BE CODED 31,04.
IZ % I(, / S Z
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR
ORIGINAL — File YELLOW — Inspector
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED. UBC
CHAPTER 3.
IO2 78
PINK — Owner GOLD — Assessor
.. ,.. „ ,,.. i.-. --
_
,
I
I
I
I
1 i
a
i
FLUE INSPECTION CHECKLIST
I
Prior to approval of a solid fuel burning appliance installation
using an existing masonry chimney, the following items must be
finspected by the owner or a professional chimney sweeper:
i
s
1. CHIMNEY LINING
Is the chimney lined with fireclay flue tile, firebrick, or
other approved lining?
_7�— YES 1-7 NO t
2. CLEARANCE TO COMBUSTIBLES
Are all combustible materials, wood framing members, etc., a
minimum of 1" away from chimney walls?
J-V YES 1-7 NO
3. GENERAL CONDITION
Is the masonry in good condition, free of cracked or broken
liners, "rotten" mortar joints, or structural defects?
9-1 YES 17 NO
Is the chimney flue free of obstructions, and thoroughly cleaned?
YES T] NO
I hereby acknowledge that I have read these inspection requirements;
that the information given is correct; and that I am the owner, or the
duly authorized agent of the owner.
i
DATE NAME