20050079.pdfDATE. RECEIVED
CITY OF EDMONDS '
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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Lu MAILING ADDRESS
( Cr;ly ZIP TEC. PHU
ADDRESS
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PERMIT EXPIRES
PERMIT
NUMBER
JOBnODRESS SUITEIAPT#
7.�'J `'j i
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO %
LID FEE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved O
RW Permit Raquvad 17
Sheet use Pormd Required E
EXISTING _ _ PROPOSED Inspection Required Cl
Sidewalk Required Q
REQUIRED DEDICATION FT underground d
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Wiring required E
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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YES O NO13 Z
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REMARKS Lu
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE Z
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t ENGINEERING REVIEWED BY DATE
a ADDRESS�
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STA LICENSE NUMBER EXPIRATIO DATE CKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
Ij•+� ^—_ REQ'D' COMPLETED I EXEMPT
O YES ONO
PROPERTY. COUNT PARCEL NO. CA# ZONE SIGN AREA HEIGHT
W ��1 f WAIVER O ALLOWED PROPOSED ALLOWED PROPOSED
/ C STUDY O
❑ NEW ❑ RESIDENTIAL / PLUMBING! MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.) '--' P ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
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.COMMERCIAL COMPLIANCE OR z
❑ ADDITION /❑ MIXED USE ❑ CHANGE OF USE z
PARKING LOTAREA PLANNING REVIEWED BY DATE
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REO'D PROVIDED
❑❑ GRADING ❑ FENCE X FT.) REMARKS
REPAIR CYDS (
13DEMOLISH 13 TANKGARAGTANK ❑
FIRE
_ 13 CARPORT El ROCKERY RETAININGWALL ❑ FIRE ALARM SPRINKLER
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OF DWELLING Ce5 SPECIAL INSPECTION CONSULTANT OCCU NT
p STORIES UNITS �''LOAD
REQUIRED L7 YES
DESCRIBE WORK TO BE DON
REMARKS z
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STRUCTURAL DESIGN
BY:
} VALUATION
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Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit City Surcharge
PLAN CHECK NO: Plumbing) Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC Grading
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE g
SEPARATE PERMISSION, Engf. Review
W
c 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
'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 OF
.j DED NDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND 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
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 # +. J
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. 1 AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• CALL Building Official or hislher Deputy: and Fees are paid, 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 INSPECTION /rg6eipt is acknowledged in space provided
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27,
OFF Ifj (GNAT E _ DTE
DATE SIGNED
SIGNATURE (OWNER 0 G NTj: n (425)�.' / 11;711195
771 =0220 RELEASE Y DA/_
=Lj
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• ORIG114AL - FILE YELLOW - INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 if IBC1101 IRC110. PINK -OWNER GOLD - ASSESSOR
10/04 PRESS HARD a YOU ARE MAKING 4 COPIES
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