20050347.pdfiDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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PLAT NAME/SUBDIVISION NO.
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PERMIT EXPIRES
PERMIT C�l�lh1 _ ff3 i� l
NUMBER
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LOT NO. v` LID NO.
Use Permit
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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YES ❑ NO ❑ z
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ADDRESS REMARKS Z
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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FIRE pEVIEv ERVED BY CITY INSPECTS
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064 VARIANCE OR CU SH IN PECTION BOND
STATE LICENSE NUMBER EXPIRATION DATE _ CHECKED BY �E �UP O'DDPOSTED_
I YES NO S
SEPA REVIEW SIGN AREA4(Fr.)
HEIGHT
PROPERTY TAX ACCOUNT PARCEL NO.. /� cc
'' COMPLETE EXEMPT ALLOWED PROPALLOWED PROPOSED
i3015,601 (/ 1 W V EXP
❑ NEW RESIDENTIAL PLUMBING/MECH LOT COVERAGE REQUIRED SETBAC�eASFLLG6TBACKS (FT.)
ALLOWED PROPOSEfZ ,.E�iQo1T:FRQONT �U�R'$IDE REAR
COMPLIANCE OR � Mrrn+u IqADDITION ❑COMMERCIAL. ❑ CHANGE OF USE ' �' � PZ
P K LOT AREA J§LAfdl1ll0.lf Wrt"Y DATE a
REMODEL ❑ MULTIFAMILY ❑ SIGN REQ'D > ww:7E� llAAll�l%%
1:1 REPAIR
REPAIR ❑ GRADING CYDS ❑ ( X FT) REMAR
❑ DEMOLISH ❑ TANK ❑ OTHER
GARAGE RETAINING WALL FIRE SPRINKLER
Z ❑ CARPORT ❑ ROCKERY ❑ FIRE ALARM
(TYPE OF USE, BUSINESS OR ATT ITY) EXP N:
Q ` CHECKED BY TYPE OFC NSTRUC ION COpF� OCCUPA►�)
ra�k .1(� S tGROUPYNUMBER NUMBER OF CRITICAL III���OF DWELLING AREAS SPECIAL INSPECTION AREA ANT
O STORIES UNITS NUMBER REQUIRED ❑
YES
DESCRIBE WORK TO BE DONE
REMARKS
;_ �`� �I PROGRESS INSPECTIONS PER UBC Joe/190109/IRC169FlNALINSPECTIONREO'D 9
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U r J S VALUATION
Description FEE Description FEE
Plan Check State Surcharge
H SOURC GLAZING % LOT SLOPE % /
Building Permit City Surcharge 0((,,JJ6
PLAN 9NECK NO: VESTED DATE Plumbing Base Fee , w
Mechanical 0
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION,
Engr, Review
W PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT. 1 YEAR -PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr, Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
*APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS Fire Review Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt k
` ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
S FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE Landscape Insp. Total Amt. Due
g 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.'
Recording Fee Receipt N
1 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
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALLThisapplication is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED Building Official or his/her Deputy: and Foes aro paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged In space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 1827.
O CIAL IGNA R j DA E
SIG URE (OWNER O AGE DATE SIGNED . (425)
' � ��- i71 0220 BELE S BYU DTE
ATTENTION EXT 1333
ITIS UNLAWFULTO USE OR OCCUPYA BUILDING OR STRUCTURE UNTILA FINAL
INSPECTION HAS BEEN MADE AND APPROVALOR A CERTIFICATE OF OCCU- ORIGINAL -FILE YELLOW- INSPECTOR
PANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110. PINK -OWNER GOLD -ASSESSOR
09/03 PRESS HARD =YOU ARE MAKING 4 COPIES
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