20050064 (2).pdfCITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF USINESS
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CITY ZIP TELEPHONE
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NAME
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PERMIT EXPIRES /
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PERMIT
NUMBER -
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ADDRESS /q
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPnnit Re
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Street Use Peered Requecd 0
EXISTING PROPOSED _ Inspection Requded O
S,duovalk Required
REQUIRED DEDICATION _ FT underground O
Wiring required 0
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES 0 N013 z
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REMARKS w
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE z
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECREQ'D CCOMPLETEDTION ED I
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10YES 0 NO
-t PROPERTY TAX ACCOUNT PARCEL NO. CA# ZONE SIGN AREA HEIGHT
Q , /J _ WAIVER 0 ALLOWED PROPOSED' ALL
PROPOSED
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❑ NEW RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SIDE REAR
COMMERCIAL COMPLIANCE OR z
❑ ADDITION ❑ CHANGE OF USE z
❑ MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g
REMODEL❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED
FENCE
GRADING
❑ REPAIR ❑ CYDS ❑ ( X FT.) REMARKS
ElDEMOLISH ElTANK ❑ OTHER
z ❑ GARAGE CARPORT ❑ RETAINING ROCKERY WALL FIRE ❑ FIREALARM LER
a(TYPE OF USE. BUSIN156SFOR C IV117y) EXPLAIN: c ,
IL / TYPE OF CONSTRUCTION l JOCCUPANT
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OF l DWELLING ' SPECIAL INSPECTION CONSULTANT OCCUPANT
O STORIES / UNITS LOAD
-� REQUIRED O YES
DESCRIBE WORK TO BE DONE
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Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE 'i
Building Permit � City Surcharge
PLAN CHECK NO: Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
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BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC dl
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DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE g
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.SEPARATE PERMISSION. Engf. Review
I w PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engf. Inspection
v *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
:1 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 r
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee Receipt # 7
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 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 hislhor Deputy: and Foes are paid, anc
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 INSPECTION receipt is acknowledged In space provided..
WORKMEN'S OMP SATI SURANCE AND RCW 18:27. "FD
OFFICIAL ATUR
IGNATURE W R OR ENT): DATE IGNED --•-
- U) 771-0220
LEASE BYATTENION EXT. 1333 IT IS UNLA FUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIG AL
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 / IBC110 / IRC110. PIN 0 ER GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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