990667.pdfDATE RECEIVED
I O b11
c
PERMIT EXPIRES
CITY S '
PERMIT / ry
ZONE Z�NUMBER 10SO66CONSTRUCTILICATION
JOB SUI,TEIAP
ADDRESS'^,OWNERNAMEINAME
OF BUSINEA7LL'I/PLAT
NAME/SUBDIVISION NO.
LO NO.
LID NO.
LID FEE S
WICATION
MAILING ADDRESSOO�A
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RWP.r Aspu4ae ❑
EXISTING PROPOSED
lr —P.rmFo ❑
SB.wwelx nuxe ❑O
CITY
_� +e�
(NAMEMETER
REQUIRED DEDICATION FT
SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIREDYES❑
NOn\uMARK.
p DRESSNTR
0—P R-11-IRI F FOR EROSION CONTROVDRAINAGE u
CITY ZIP TELEPHONE
NAME
cD ADDRESS
U
FIRE REVIEWED BY DATE Q
ti
CITY ZIP
TELEPHONE
D
U
VARIANCE OR CU
SHORELINE OR ADBp
INSPECTION
REQ'D
DYES (:)NO
BONG
POSTED
STAT2LICENSE NUMBER EXPIRATION DATE
CHECKED BY
SEPA REVIEW
COMPLETE I EXEMPT
EXP
SIGN AREA
ALLOWED PROPOSED
HEIGHT
ALLOWED PROPOSED
PROPERTY TAX ACCOUNT PARCEL NO. /
❑ NEW ( RESIDENTIAL ❑ PLUMBING I MECH
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (Fr.)
FRONT SIDE REAR
PROPOSED SETBACKS(FTJ
FRONT UR SIDE REAR O
❑ ADDITION ❑ COMMERCIAL ❑ CHANGE OF USE
z
PARI(ING
LOT AREA
PLANNING REVIEWED BY DATE a
REMODEL ❑ APARTMENT ❑ SIGN
REO'D
PROVIDED
❑ REPAIR ❑ GRADING CYDS ❑ iENCE X FT)
AR
S
❑ DEMOLISH ❑ TANK ❑ OTHER
GARAGE ❑ETAIN RING WALL
❑ CARPORT ❑ RENEWAL
O 6
(
F
IN
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
CHECKED BY
TYPE OF COy$TRUCTION
CO GROUP
w
R
o
NUMBER
OF
STORIES
NUMBEROF
DWELLING
UNITS
CRITICAL
AREAS
NUMBER
SPECIAL INSPECTOR
REQUIRED❑YES
AREA OCCUPANT
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS PER UBC 1081FINAL INSPECTION REO'D 2
VALUATION
FEE
(D
PLAN CHECK FEE
HEAT SOURCE GLAZING % LOT SLOPE %
BUILDING
/� I
PLAN CHECK NO: 115TEO DATE
PLUMBING
MECHANICAL
PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
E DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
GRADINGIFILL
OMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
STATE SURCHARGE
PERMIT APPLICATION: 1B0DAYS
YEAR -PROVIDED WORK STARTED WITHIN 18o DAYS
PERMIT LSEE
F-�-_JALL
EKG. REVIEW FEES
M
BEE BACK OF PINK PERMIT FOR MORE INFORMATION
B
FEE
LICANT. ON BEHALF OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
TEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
LMOSCAPING
ONDS. WASHINGTON. ITS OFFICIALS. EMPLOYEES, AND AGENTS FROM ANYANDCLAIMS FOR DAMAGESOF WHATEVER NATURE,ARISING DIRECTLYOR INDIRECTLY
RECEIPT
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
_ OR LIMIT IN ANY WAYTHE CITY'S ABILITY TO ENFORCE ANYORDINANCE PROVISION'
TOTAL AMOUNT DUE
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
This applicallon Ia npl a pormil unlll slpnetl by IM10
THE OWNER. (AGREE TO COMPLY WITH CITY AND STATE LAWSREGULATING CONSTRUC
EMPLOYED
CALL
Building 011lci.l hlslhur Dopuly: end Faes aip paitl. antl
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PER SON WILL BE
STATE OF WASHINGTON RELATING TO
FOR INSPECTION
ocoipl is acMnowtpdgotl in apace prpvidotl.
IN VIOLATION OF THE LABOR CODE OF THE
WORKMEN'S COMPENSATION INSURANCE AND RCW IB.Z].
OFFICIALS NAiIE ATTUD
SIGNA OWNS DATE(S�IGNE/D
(425)
L / 1
0220
111
RELESEDGY DATE
E TION
EXT 333
IT IS UNLAWFULTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221
BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGIN_ INSPECTOR
RI IN
A FINAL INSPECTION HAS
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
ASSESSOR
`OWNER • GELLOW LD
5198
.• �, -. __.._._ _ _.._'' --- ._ ... _ _ - _
DATE RECEIVED
r .� D I-
C� �j
PERMIT EkPIREa..'
ZONE
PERMIT
I Z_..' 99066
CITY OF EDMONDS
' \ " NUMBER
CONSTRUCTION PERMIT APPLICATION ADDRESS
SUITE/APTn
cI c) L ,•n LC (f I J ig
OWNER NAME/NAME OF BUSINESS
PLAT NAMEISU9DIVISION NO.
LO N0.
LID NO.
N S
LID FEE S
w
MAILING ADDRESS
1( J„
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TEscv npP,wea p-'
qw ve,mn ReQu�ea ❑
r,.IDea ftReId D
q
O O O CJJ
O
F�eu.ee
CITY - TELEPHONE
EXISTING PROPOSED
p
!IP
-7-7
REQUIRED DEDICATION FT
Wlring requnee
METER 512E LINE SIZE NO.OF FI%TURFS
PRV REQUIRED
NAME
YES ❑ NO ❑ -
REMARKS
-
ADDRESS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROVDRAINAGE
C
CITY zip TELEPHONE
NAME
-
ENGINEERING REVIEWED/DATE
ADDRESS
O
FIRE REVIEWED BY DATE
Z.
O.
CITY ZIP
TELEPHONE
1
0
O
VARIANCE OR CU
SHORELINE OR ADS.
INSPECTION
REO'D
BOND
POSTED
(.
rn.
STATELICENSE NUMBER E%PIRATION DATE
CHECKED BY
OYES ❑NO
•
SEPA REVIEW
SIGN AREA
O:
HEIGHT
D PROPOSED
�•I iI
� PA
PROPERTY TAX ACCOUNT RCEL NO.
COMPLETE EXEMPT
A
, ,
o
EXP I
'D
=
C I
❑ NEW
�
lQ'R591DENTlAI�.'-
•Q=PLUMBING/MECH,:�
-�-L9T COVERAGE
ALL�IWEO PROPOSED
I BA S .)
FRONT SIDE REAR
SETBACKS (FT.)
FRONT VR SIDE REAR -
(R O
Y
❑ ADDITION
❑ COMMERCIAL
COMPLIANCE OR
❑ CHANGE OF USE
BY DATE a
O C
�� I -
PARKING
LOT AREA PLANNING REVIEWED
REMODEL
❑ APARTMENT
❑ SIGN
flE0'D PROVIDED
= rn
mZ
❑ REPAIR
FENCE
❑ GRADING CYDS ❑ ( X FT)
RE APKS
io 1
�.
❑ DEMOLISH ❑ TANK ❑ OTHER
^ III
-O'L/,•
D
GARAGE ❑ RETAINING WALL ❑ RENEWAL
❑CARPORT
Ia
F (TYPE OF USE. BUSINESS OR ACTIVITYI EXPLAIN:
CHECKED BY
TYPE OF COy$.TRLLCTION
CO GROUPA
GROUP JZa
yC
-
�F/- N
m m
w NUMBER
NUMBER OF
CRITICAL
AREAS
SPECIAL INSPECTOR
AREA
OCCUPANT
-
(n .
O OF.
G STORIES
DWELLING
"UNITS
NUMEEfl
flEOUIRED❑YES
LOAD
O I:
G
DESCRIBE WORK TO BE DONE
r
PEE��ttARKS
PER UBC 108/FINAL INSPECTION REQ'D 'o
C N,
Ul.
PRbGRESS.INSPECTIONS
T
rJl /' �z
Z
a•. s
/'.
TJ
LI
Z
�'
VALUATION
FEE
0) 1.
/ w
Z.
AN CHECK FEE
PLAN
O
HEAT SOUflCE GLAZING ^h l+ LOT SLOPE %�S
BUILDING
I
V . �J
0
Gcs
rn
PLAN CHECK NO:-sTED DATE
PLUMBING
MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
ETC.) WILL REQUIRE
GRADING/FILL
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES,
SEPARATE PERMISSION.
STATE SURCHARGE
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT:1 YEAR • PROVIDED WORK IS STARTED WITHIN 180 GAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
N •APPLICANT,ONBEHALFOFHISORHER SPOUSE, HEIRS. ASSIGNS AID SUCCESORS
TO INDEMNIFY, DEFEND AND HOLD HPRMLESS THE CITY OF
ENG. INSPECTION FEE
_
�-
LANDSCAPING
IN INTEREST, AGREES
E EDMONDS, WASHINGTON, ITSOFFICIALS, EMPLOYEES, AND AGENTS FROM ANYAND
INSPECTION FEE
ALLCLAIMSFORDAMAGESOF WHATEVER NATURE, ARISING DIRECTLYUfliNDiRECTLY
ISSUANCE OF THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
RECEIPT
FROM THE ISSUANCE OF THIS PERMIT.
O DEEMEOTO MODIFY,WAIVEOR REDUCEANY REQUIREMENT OF ANY CITY ORDINANCE
1\\
03
1
/
i NOR LIMIT IN ANY WAYTHE CITV'SABILITY TOENFORCE ANYORDINANCE PROVISION.'
TOTAL AMOUNT DUE
RECEIPT L
���•
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT; AND THAT 1 AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
This applicellon Is not a pprinil until signed by the
THE OWNER. 1 AGREE TO COMPLY WITH CITY AND STATE LAW S REGULATING CONSTRUE CALL
guiltlinq 011icial or hislhpr DePNY: Old Fpee pro paid, entl
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
RELATING TO FOR INSPECTION
rOc pl is a,klowIddgatlin apace p,oritlod.
Il -
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
OFFICIALS NATURE DATE I
SIGNAT RE WNER GR'A�EN.TI
DATE SIGNED �/ l-/' 425
/
I
L/����
f/ - / / /. 71 -0220
RELEPSED BY DATE
EXT 333
A E TION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771 _0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORII IN L-FFILEPINK-OWNR •• GOLD ASSESSOR INSPECTOR
HAS BEEN GRANTED. UBC SECTION 11�0'9�/�//>/� FAX
CATE OF OCCUPANCY „
/�/(K l /./�
:;. 5158/�. //a/ •'YitZs/_ '_ a�(/(Y/ fl �0• • ... -