20020310.pdfGATE
"VIZ,510
C sPERMIT EXPIRES
CITY OF EDMONDS
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ONE -70 NUMBS _03jj
CONSTRUCTION PERMIT APPLICATION
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JOB
HER NAMEIMN E OF BUSINESS
SUITE/APT#
ADDRESS
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PLAT NAMEISUBDIVISION NO, LOT NO, LID NO.
MAILING ORE35
I LID FEE S
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CITY
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP T�E— a—
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ZIP TELEPHONE
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EXISTING — PROPOSED — se-s- Kemase
REQUIRED DEDICATION— FT
NAME
METER SIZE I LINE SIZE I NO. OF FIXTURES PRV REQUIRED
YES E3 NO E3
G
ADDRESS
REMARKS
CITY
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIORAINAGE
Ul
an
1112-0
ADDRESS
ENGINEERING REVIEWED/DATE
TELEPHONE
FIRE REVIEWED BY DATE
"AN'Ars" On CU SHORELINE OR ADB# I INSPECTION I SON
.1 — NO.
61V 6
COMPLETE
COMPLETEEXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
La La
Exp ,
,
,
NEW
0 RESIDENTIAL
[3
LOT
LOT COVERAGE
REQUIRED SETBACKS (FT.) PROPOSE
SETBACKS (Fr.
pLUMSING I MECH
LOWE
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT US SIDE REAFI
[3 ADDITION
[3 COMMERCIAL
o C MPLIANCE OR
CHANGE OF USE
[3 REMODEL
[3 APARTMENT
E3 SIGN
P
G PARKING
REQ'PA I PROVIDED
LOT AREA
PLANNING REVIEWED BY DATE
0 REPAIR
❑ GRADING
FENCE
OYDS
[3 , — " — Fr)
DEMOLISH
0 TANK
❑ OTHER
O
CAGARPRAORGET
ROOKERY 0 RETAIN""'
❑RENEWAL
ITYPE OF USE, RUSINr OR ACTIVITY) EXPLAIN:
CHECKED BY
ITYPE 2NST
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I a Rou,
OCCUPAN��
NUMBER
^7
NUMBER OF
DWELLING
CRITICAL
AREAS
RRUCT
4
SPECIALOF INSPECTOR
-
OCCUPANT
JAREA
QUIRED [] YES
LOAD
DESCRIBE WORK TO 09
DONE
REMARKS
6,
PROGRESS INSPECTIONS PER UBC 108/11FINAL INSPECTION REOtD
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.------___I_VALUATION
$
F—D.;.apth.. I
FEE
Description
FEE
Plan Check
Plan Chao"
H1 GLAZING %
L
LOT
LOT SLOPE %
SLOPE %
GE
Building
Building
PLAN CHECK NO:
VESTED OATS
VESTED DATE
Plumbing
Plumbing
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PE PBUT COVER OR
Mechanical
Mechanical
Me h
2
BE DOME ON PRIVATE PROPERTY ONLY ANY CONSTRUCTION ON THE Us C
PU LID
d
Grading
Grading
=1
a
DOMAIN(CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, FTC.) WILL REQUIRE
...) WILL IN
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: 100 DAYS
PERMIT M Mi YEAR D WORK IS STARTED WITHIN 190DAYS
Engr. Inspection
O;PROVID
SEE BACK PINK PERMIT FOR MORE INFORMATION
'APPLICANT. ON BEHALF OF HIS an HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE Oil 01
Traffic Mitigation
— —
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Review
A
VLLCLAa S FOR DAMAGES OF WHATEVER NATURE, ARIS NO DIRECTLY OR INDIRECTLY
FROM THE
T ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
9 DEEMED TO
Fire Inspection
MODIFY, WAIVE OR REDUCE ANY CITY ORDINANCE
REQUIREMENT OF ANY
01 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Landscape insp.
I HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
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 CONSTRUC.
CALL
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTII
WORKMEN'S COMPENSATI URANCE AND RCVV 1827.
SIGNATURE (OWNER 0 AGENT) DATE SIGNED
4
(421
1
771-0220
ATTENTION
E)ff 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR SUCTURE
TR
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CSRTIFUNTILI-
771-0221
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
tolol
Recording Fee
City Surcharge
State Surcharge
Plan Chk Deposit
Receipt #
TotalfianoumDue
Receipt #
APPLICATION APPROVAL
This ppleatishis sets permit until signed by she
Nfflaitaji�or ha�siher.Depmy! end Fees a, paid, and
me rryk a rXr.dIn.jqIa.p—Id,nL
VEASED BY DATE
ORIGINAL -FILE - YELLOW -INSPECTOR
PINK -OWNER - GOLD -ASSESSOR
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