20050081.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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PLAT NAME/SUBDIVISION NO. LOT NO.
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTINGi PROPOSED
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LID NO.
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STATE LICENSE NUMBER PIRATION DATE HE KED VARIANCE tilt] NE A&Q�li, REQTION
ro $� �AlacA l' J YES 0 NO OMPLETED EXEMPT
CAU NE SIGN AREA HEIGHT
PROPERTY TAX ACCOUNT PARCEL NO.
�� WAIVER O ALLOWED PROPOSED ALLOWED � PROPOSED
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❑ NEW I R RESIDENTIAL l MBING I ECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
�" ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR t7
❑ COMMERCIAL NCE OR z
❑ ADDITION ❑ CHANGE OF USE z
❑ MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REO'D PROVIDED
GRADINGFENCE
REPAIR 13CYDS ❑ ( X FT.) REMARKS
❑ DEMOLISH ❑ TANK ❑ OTHER
GARAGE ❑ CARPORT ❑ ROCKENING RY WALL FIRE ❑ FIRE ALARM LER
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
NUMBER VV( NUMBER OF
OCCUPANT
GROUP
OF
DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES UNITS q LOAD
REQUIRED
DESCRIBE WORK TO BE DONE L.1 YES
REMARKS
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BY: ,
STRUCTURAL DESIGN
BY:
(' VALUATION
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Description FEE Description FEE
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~„ Plan Check State Surcharge
HE OUR LOT SL E% ESTED DATE
Building Permit City Surcharge
PLAN CHECK NO: Plumbing ` Base Fee r
THIS PERMIT AUTHORIZES ONLY T E WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
E DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
i SEPARATE PERMISSION, Engr. RBVIeVJ
u PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
> PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engr. Ir1SOP.CIIOn
n 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS FIfC Review Plan Chk. Deposit
L IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
I 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 r_
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 # n�
1 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 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 ODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSA S ANCE AND RCW 16:27. OFFI J� SlqNATUDAIE
SIGN JURE IOW R G T): DAT7SNED (425)C�1 / '
lj{i( L / U 771 -0220 RELEASED BY DATE
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• ORIGINAL • FILE YELLOW • INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 if IBC110 1 IRC110. PINK -OWNER GOLD '• ASSESSOR
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