20050442.pdfI DATE RECEIVED
CITY OF. EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
PA 4'1
MAILING ADDRESS
CITY ZIP TELEPHONE
MOAIZ5 W020 77::>68
NAME
PERMIT EXPIRES_._7��
PERMIT )
NUMBER�1_,!
JOB SUITEIAPTp
ADDRESS
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
LID FEE
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved 0
RW Permit Requited E3
Street Use Permit Required 0
EXISTING _PROPOSED Inspection Requited O
Sidewalk Required [7
REQUIRED DEDICATION FT Underground O
Witing required O
METER SIZE LINE SIZE NO, OF FIXTURES PRV REQUIRED
YES D NOD Z
REMARKSO {{II�� i TT ����?? nn W
OWNER/CONTRA OF7FtESPbNSJl6[.Ei�6WRC1SIt�t�OR�1? UDRAINAGE z
t7
• STREL111 '1'O 1.3E CLEANED OF DEBRIS W
• SIDE SEWER MUST BE CAPPEID AT
_011102111114 Fill
— • n r- t `—t1 1\ 1 ENGINEERIIM R AMIq
IX ADDRESS iB wITH AVB INSTATA.,
•, C FIRE REVIEWED BY T
0 CIS p. ZIP TELEPHONE J. SEB DEMOLITION INSPECTION LL
STATE LICENSE NUMBER EXPIRATION TE EGKED Y VARIANCE OR�Jgf�� EPA O
• ��- `ta..�wv OMPLETED EXEMPT �I
L• f� DYES D NO
I;7
C PROPERTY TAX ACCOUNT PARCEL NO.
Cad A#(W-4)('1% - ZONE SIGN AREA HEIGHT M
W IJ 2 p0 d WAIVER'9 ALLOWED PROPOSED ALLOWED PROPOSED
STUDY D \ —{
1:1NEW RESIDENTIAL ❑ PLUMBING I MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.) Cir
ALLOWED PROPOSED FRONT SIDE REAR FRONT LIR SIDE REAR
❑ADDITION ❑ COMMERCIAL COMPLIANCE OR i C rn
❑ CHANGE OF USEz rn C
❑ MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g -i
1:1 REMODEL ❑ MULTIFAMILY ' ❑ SIGN REO'D PROVIDED ° Q C
1:1 REPAIR ❑ GRADING ❑ FENCE = rn
CYDS ( X FT.) REMARKS rn
OTHER Z
AEJOO�DEMOLISH ❑ TANK ❑ 10
Z ❑GARAGERETAINING WALL FIRE SPRINKLER D Z
CARPORT ❑ ROCKERY ❑ FIRE ALARM r—
F (TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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TYPEQF CONSTRUCTION CA D En
OCCUPANTGRO O rn
Lu NUMBER NUMBER OF I
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m OF / DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT -'i
I O STORIES [[ UNITS / LOAD _
DESCRIBE WORK TO BE DONE REQUIRED YES jjj M
REMARKS z O re
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VALUATION
$
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Description FEE Description FEE ) Z
Plan Check State Surcharge T
co
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit 1 ` City Surcharge Z
(j�jCii � O
PLAN CHECK NO: p 6S Plumbing Base Fee -D `7 M
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
t BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBIC
2 DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
I= SEPARATE PERMISSION.
s Engr. Review
PERMIT APPLICATION: SEE ECDC 19,00,005(A)(5)
OLU
o PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION g ' p
"APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES cAND AGENTS FROM ANY AND Fire Inspection Receipt #
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
e DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due )
_ NOR LIMIT IN ANY WAY THE CITY's ABILITY TO ENFORCE ANY ORDINANCE PROVISION,*
Recording Fee 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
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• This application Is not a permit until signed by the
TION; AND IN,DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or his/her Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged to space provided
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27,
Cl S IGN TURE DATE
s� TUR (Ow& RAGENT): DAT712 SIGNE (425)
Z 771=0220 RE A D BY .
L D E
ATTENTION EXT. 1333 -
IT IS UNLAWFUL TO 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 I IBC110 I IRC110• ORIGINAL FILE YELLOW - INSPECTOR
PINK -OWNER •GOLD •ASSESSOR
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