20050469.pdfDATE RECEIVED
OZ PERMIT EXPIRES AK z7i
PERMIT
CITY OF EDMONDS NUMBER
CONSTRUCTION PERMIT APPLICATION J0° ITEIAPT#
ADDRESS
OWNER NAMEINAME OF BUSINESS 1UC
A�� (�1 i / �� ` PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
to
MAILING ADDRESS / LID FEE $
r� V PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved 13
RW Permit Requited
Street use Permit Requced O
CITY ZIP TELEPHONE C EXISTING PROPOSED _ Inspodion Requited O
Sidewalk YWO /g `7 Z� 4 Z�7 V G�� underground
,raced O
REQUIRED DEDICATION FT Wm required O
NAME I METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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ADDRESS REMARKS i
Q A `. � I� _ 1 C� OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
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CITY ZIP TELEPHONE
NAME ` CBL#
ENGINEERING REVIEWED BY DATE
AURES
FIRE REVIEWED BY DATE
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CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION GATE CHECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
REQ'D COMPLETED I EXEMPT
OYES ONO
CA# ZONE SIGN AREA HEIGHT
PROPERTY TAX ACCOUNT PARCEL. NO.
V, ^ O .. WAIVER O_ ALLOWED PROPOSED ALLOWED PROPOSED
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❑NEW RESIDENTIAL PLUMBING I MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
❑ ALLOWED PROPOSED FRONT SIDE REAR FRONT LIR SIDE REAR t,
1:11:1COMMERCIAL COMPLIANCE OR z
❑ ADDITION CHANGE OF USE Z
❑ MIXED USE PARKING LOTAREA PLANNING REVIEWED BY DATE a
REMODEL ❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED
❑ REPAIR ❑ GRADING ❑ FENCE
CYDS X FT.) REMARKS
❑ DEMOLISH ❑ TANK ❑ OTHER
Z . ❑GARAGE RETAINING FIRE SPRI
CARPORT ❑ ROCKERY WALL ❑ FIRE ALARM LER
a(TYPE OF USE, BUSI SS ORgCTI ITY) yy 0%EXP IN�
J0.1 n TYPE OF 0 S UCTION CODE GROUP OCCUPANT
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GNUMBER NUMBER OF
OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
M STORIES - UNITS LOAD
REQUIRED D YES
DESCRIBE WORK TO BE DONE
` . \ REMARKS z
bJ •, GEOTECH REPORT
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VALUATION
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Description FEE Description FEE ��yy•
Plan Check "� State Surcharge •J[��
E�TOURCE LOT SLOPE%VESTED DATE 11J�
'nom Building Permit l�� City Surcharge ,J
PLO CHECK NO: -- Plumbing 1 Base Feed
Mechanical 5THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT.COVERS WORK TO
? •`
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC Gradin
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE g
It= SEPARATE PERMISSION,
a Engr. Review
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PERMIT APPLICATION: SEE ECDC 19,00.005(A)(5)
a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
1111 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
U IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY O.F
N EDMONDS• WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt # '
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 MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due q� L)
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee Receipt #
I HEREBY ACKNOWLEDGE THAT 1 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 application is not a permit until signed by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL Building Official or his/her Deputy: and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION receipt is acknowledged in space provided.
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENS*PIKS
URANCE AND RCW 18:27. FIC LS SIGNATU PATE
4SIGNATUREOWNE AGENT): DATE SIGNED(425)VD771-0220 REL DATN EXT. 1333WFUL TO USBOR OCCUPY A BUILDING OR STRUCTURE UNTIL �• /
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL - FILE YELLOW ANWECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 I I8C1101 IRC110, PINK -OWNER GOLD- ASSESSOR
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