20050050 (2).pdfDATE RECEIVED /
PERMIT EXPIRES
CITY OF EDMONDS
PERMIT
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CONSTRUCTION PERMIT APPLICATION JOB SUITE/APT#
ADDRESS
OWNER NAMEINAME OF BUSINESS
PLAT NAMEISUBDIVISION NO. U�f NO. LID NO
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MAILING ADDRESS s�V LID FEE $
3 M EI 5 f �� 1,/t PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW PermCP pp Requovedired
0
0 ;J LJ WI'r /`� RW Permit Rogwrad 0
Street Use Pumut RegwwO 0
CITY ZIP TELEPHONE EXISTING_ PROPOSED Inspection Requited 0
0
h 8 2c Sidewalk Required
t&M Did i✓ O �317REQUIRED DEDICATION FT Underground 0
Winno required 0
NAME METER SIZE LINE 512E NO. OF FIXTURES PRV REQUIRED
YES 13 NO 13 z
L3 X
W W
t ADDRESS REMARKS W
UOWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROU'DRAINAGE z
Z
a W
CITY ZIP TELEPHONE
NAME CBL
WC45 CSO K ENGINEERING REVIEWED BY DATE
cc ADDRESS
Lt FIRER VIEWED BY. DATE W
z CITY ZIP TELEPHONE r , LL
STATE LICENSE NUMBEREXPIRATION DATEAECK BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
REQ'D GOIdPLETED EXEMPT
aTi] YES E3NO
CA# ZONE SIGN AREA HEIGHT
PROPERTY TAX ACCOUNT PARCEL NO.
6 WAIVER 13 ALLOWED PROPOSEDALLOWED PROPOSED
STUDY C3
NEWRESIDENTIAL ❑ PLUMBING if MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
®
P ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
❑ COMMERCIAL COMPLIANCE OR z
❑ ADDITION ❑ MIXED USE ❑ CHANGE OF USE z
❑ PARKING LOT AREA PLANNING REVIEWED BY DATE g
❑REMODEL
MULTIFAMILY 13 SIGN REO'D PROVIDED
❑❑ GRADING ❑ FENCE X FT.) REMARKS
REPAIR CYDS
❑ DEMOLISH TANK i_p C12P) ❑ OTHER
Z ❑GARAGE RETAINING WALL FIRE SPRINKLER
CARPORT T❑' ROCKERY ❑ FIREALARM
(TYPE OF USE, BUSIN SS OR ACTIVITY) EXPLAIN: TYPE OF WNSTRUCTION CODE OCCUPANT
r 1� 1 O Yh 1] GROUP
U
LU
N MBER NUMBER OF
OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
MSTORIES UNITS LOAD
REQUIRED O YES
D RISE V#ORK TO BE DONE h r-' �
l V ,^ REMARKS _
b(% l GEOTECH REPORT
BY: IRE MARLSHAI
ADM P
� I 0 I ( STRUCTURAL DESIGN
BY: MUST BE PRESENT FOR
AA rooe VALUATION TANK FILL, REMOVAL, OR CAP
G I Doe e,(i Description FEE 7Description FEE
�31'DS Plan Check charge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit 27-" City Surcharge
PLAN CHECK NO: Plumbing Base Fee
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
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE Grading
SEPARATE PERMISSION.
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5) Engr. Review
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
m
*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
M EDMONDS, WASHINGTON, ITS OFFICIALS; EMPLOYEES, AND AGENTS FROM ANY. AND Fire Inspection Receipt 0
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 Landscapo Insp. Total Anil. Duo
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.' _
Recording Fee Receipt N ?
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 applicalion is nol a pound until signed by the
THE OWNER. 1 AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• CALL tdd+ng Official ar hislhur Deputy and Feus fire quid, and
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 IN
fOCO1PI is ac�itnwledgud m spare prnwdud
WORKMEN'S COMPENSATION INSURANCE AND RCW 16:27. a I lum: DATE
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ATURE (OW ER GENT): DATE SIGNED (425)
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ENTIONN 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- ORIGINAL jill YELLOW -INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 1 IBC110 1 IRC110, PINK .0WNFR • GOLD - ASSESSOR
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